Buckeye Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow enhanced barrier precautions (EBP) as guided by the Centers for Disease Control and Prevention (CDC) for Resident #4 and failed to ensure hand hygiene was performed during catheter care for Resident #9. This affected two of five residents reviewed for infection control. The facility census was 88.Findings include: 1.Review of the medical record for resident #4 revealed an admission date of 06/06/25 with diagnoses including inflammatory disorders of scrotum, gangrene fournier, dementia, and cerebral infarction. Review of physician's orders dated 10/04/25 revealed an order for enhanced barrier precautions during high contact resident care two times a day for foley catheter. Observation on 01/08/26 at 1:28 P.M. revealed a bed bath being performed by CNA #665 with Resident #4. Interview on 01/08/26 at 1:31 P.M. with CNA #665 verified the signage was posted on the door for enhanced barrier precautions due to resident having a catheter…

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 and interview the facility failed to ensure Resident #52 ' s wheelchair was maintained in a clean and sanitary manner. This affected one resident (#52) of three residents reviewed for environment. The facility census was 88.Findings include:Review of Resident #52's medical record revealed an admission date of 05/28/21 with diagnoses including Parkinson's disease, Type II Diabetes Mellitus, progress multiple sclerosis, mild cognitive impairment, unspecified protein-calorie malnutrition, legal blindness, dementia, and major depressive disorder.Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Observation on 01/06/26 at 2:50 P.M. and on 01/08/26 at 10:05 A.M. revealed Resident #52's wheelchair had a large build up of dirt, food, stains, and splatters along the sides and edges.Interview on 01/08/26 at 10:05 A.M. with the Director of Nursing (DON) verified Resident #52's wheelchair needed cleaned, she reported it 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 observations, medical record review, staff interview, and facility policy review, the facility failed to report an alleged violation to the state department of health in a timely manner. This affected one (Resident #43) of three incidents reviewed. The census was 93.Findings Include: Observation on 11/17/25 at approximately 11:55 A.M. revealed Resident #43 lying in bed with a white towel lying over her right shoulder/upper arm area. She was observed with a slight grimace as if in pain. Resident #43 was admitted to the facility on [DATE]. Her diagnoses were Parkinson's disease, abnormal posture, mild cognitive impairment, muscle weakness, dementia, unspecified protein calorie malnutrition, herpes-viral vesicular dermatitis, dysphagia, mixed hyperlipidemia, major depressive disorder, obesity, anxiety disorder, hydrocephalus, psychosis, hypertension, obstructive sleep apnea, Type II Diabetes, vitamin D deficiency, chronic ischemic heart disease, mood disorder, weakness, drug induced subacute dyskinesia,…

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, interviews, record reviews, and review of facility policy, the facility failed to ensure wound care treatment and assessments were appropriately implemented and completed. This affected one resident (#76) out of three residents reviewed for wound care. The facility census was 93.Record review for Resident #76 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, dementia, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, revealed the resident was assessed to have impaired cognition.Review of the nurses' progress note, dated 04/07/25, revealed right thigh healed. Treatment orders discontinued.Review of the care plan, revised 06/25/25, revealed the resident was at risk for impaired skin integrity. Interventions included blister to right thigh (05/10/25).Review of the facility eINTERACT SBAR (Situation, Background, Appearance, Review) form, dated 05/09/25, revealed the resident was assessed to have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interview, the facility failed to ensure residents remained free from burns. This affected one resident (#76) out of three residents reviewed for accidents. The facility census was 93.Record review for Resident #76 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, dementia, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/25, revealed the resident was assessed to have impaired cognition.Review of the nurses progress note, dated 02/20/25, revealed Resident #76 had spilled coffee on himself during lunch. The resident would not allow staff to remove his pants to assess the area where coffee had spilled.Review of the nurse progress note, dated 02/20/25, revealed Resident #76 had been brought back from the dining area after he had spilled coffee on himself. The nurse completed a head-to-toe assessment, and a blister was present to the right outer leg with some redness noted. The immediate…

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 interview and closed medical record review, the facility failed to ensure blood draw orders were obtained for Resident #110 who was receiving Vancomycin (strong antibiotic) intravenously per standards of care. This affected one (Resident #110) of three residents reviewed for intravenous medication administration. The facility census was 97. Findings include: Review of the closed medical record for Resident #110 revealed an admission date of 03/20/25, discharged to hospital on [DATE], returned to facility on 05/07/25 and discharged home on [DATE]. Diagnoses included acute osteomyelitis of right ankle and foot, peripheral vascular disease, diabetes mellitus type two, abscess tendon sheath of right ankle and foot. Upon return from hospital stay resident was diagnosed with metabolic encephalopathy and altered mental status. Review of the physician orders upon admission revealed Resident #110 was ordered Vancomycin hydrochloride intravenous solution 1250 milligrams/250 milliliters, use 250 milliliters (ml)…

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, policy review and interview, the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#12, #30 and #31) observed for incontinence care and one resident (#45) of one resident self-propelling in the hallway. The facility census was 87. Findings include: 1. Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including multiple sclerosis, Parkinson's disease, altered mental status and urge incontinence. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact for daily decision-making and was frequently incontinent of urine. Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including dementia, urinary tract infections, cognitive communication disorder, contractures and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact for daily…

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, controlled drug sheet review, policy review and interview, the facility failed to ensure a comprehensive program to safeguard controlled substances and ensure medications were administered as ordered. This affected four residents (#18, #21, #38 and #102) sampled during reconciliation of controlled substances and one resident (#36) of three residents reviewed for infection. The census was 87. Findings include: 1. On 05/01/25 between 6:15 A.M. and 6:45 A.M., observation of reconciliation of controlled drugs for the Maple Avenue Hall and Main Street Hall revealed the following: a. Reconciliation of controlled medications with Registered Nurse (RN) #235 and Licensed Practical Nurse (LPN) #236 for Maple Avenue Hall revealed RN #235 opened the medication cart and unlocked the narcotic drawer. The locked narcotic drawer contained bubble packs of medications, transdermal patches, a community-filled prescription bottle and a disposable water cup that contained two pill-crusher…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, self-reported incident (SRI) review, medical record review, policy review and interview, the facility failed to safeguard controlled substances to prevent misappropriation. This affected one resident (Resident #13) of three residents identified in a self-reported incident. The facility census was 87. Findings include: Medical record review revealed Resident #13 was admitted on [DATE] with diagnoses including diabetes mellitus, fracture of left tibia and fibula, benign prostatic hyperplasia, heart failure and urinary tract infection. Review of the SRI tracking number 258836 dated 03/30/25 revealed when the facility tried to reorder Resident #13's oxycodone (opioid), the pharmacy indicated that the medication could not be refilled as it was too soon. The pharmacy reported that 60 tablets of oxycodone 5 milligrams (mg) had been delivered to the facility on [DATE]. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to timely assess an indwelling catheter, treat urinary tract infections and provide adequate incontinence care. This affected one resident (#13) of three residents reviewed for urinary tract infections and one resident (#12) of one resident observed for incontinence care. The facility census was 87. Findings include: 1. Medical record review revealed Resident #13 was admitted on [DATE] with diagnoses including left fibula and tibia fracture, heart failure, chronic kidney disease, benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, and urinary tract infection (UTI). Review of the Foley Catheter Evaluation dated 02/28/25 revealed Resident #13's indwelling catheter was being utilized for better pain control and mobility. The evaluation was to be completed upon admission, weekly for four weeks and then quarterly thereafter. The goal was to minimize the invasive methods used for resident safety, health,…

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, policy review and interview, the facility failed to provide adequate care and services for a gastrostomy tube during medication administration. This affected one resident (#51) of three residents with an enteral tube observed for medication administration. The facility census was 87. Findings include: Medical record review revealed Resident #51 was admitted on [DATE] with diagnoses including dysphagia, nontraumatic intracranial hemorrhage, congestive heart failure, gastrostomy and dementia. Review of Resident #51's Order Summary Report dated May 2025 revealed the resident was ordered a regular diet, pureed texture and thin liquids. The resident was to receive 200 milliliters (mL) bolus of water twice a day. On 05/01/25 between 8:15 A.M. and 8:23 A.M., observation of Resident #51's medication administration revealed Licensed Practical Nurse (LPN) #230 prepared the following medications: Xanax 0.5 milligrams (mg) (antianxiety), Percocet 5/325 mg (opioid), allopurinol…

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, policy review and interview, the facility failed to provide adequate care and services for a gastrostomy tube. This affected one resident (#51) of three residents observed for medication administration with 12 errors out of 25 opportunities resulting in an error rate of 48%. The census was 87. Findings include: Medical record review revealed Resident #51 was admitted on [DATE] with diagnoses including dysphagia, nontraumatic intracranial hemorrhage, congestive heart failure, gastrostomy and dementia. Review of Resident #51's Order Summary Report dated May 2025 revealed medications could be crushed and given with food if appropriate. Further review revealed no order to administer medications via Resident #51's enteral tube. On 05/01/25 between 8:15 A.M. and 8:23 A.M., observation of Resident #51's medication administration revealed Licensed Practical Nurse (LPN) #230 prepared the following medications: Xanax 0.5 milligrams (mg) (antianxiety), Percocet 5/325 mg…

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, policy review and interview, the facility failed to ensure medications were labeled as required. This affected one resident (#21) of four residents sampled during reconciliation of controlled substances. The census was 87. Findings include: Medical record review revealed Resident #21 was admitted on admitted on [DATE] with diagnoses including osteoporosis, spinal stenosis, chronic pain, osteoarthritis and joint pain. Review of the electronic Physician Orders dated 05/01/25 revealed Resident #21 was ordered oxycodone 5 milligrams (mg) every eight hours PRN (as needed) for pain rated a one to 10. Review of Resident #21's oxycodone 5 mg Controlled Drug Receipt/Record/Disposition Form (CDR) revealed there was a supply of 65 tablets available for use. On 05/01/25 between 6:15 A.M. and 6:45 A.M. observation of reconciliation of controlled drugs with Registered Nurse (RN) #235 and Licensed Practical Nurse (LPN) #236 for Maple Avenue Hall revealed RN #235 opened 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, policy review and interview, the facility failed to monitor/log infections and possible trends and failed to perform handwashing when indicated. This affected one resident (#30) of three residents observed for incontinence care and one resident (#36) of three residents reviewed for urinary tract infections. The census was 87. Findings include: 1. Medical record review revealed Resident #36 was admitted on [DATE] with diagnoses including respiratory failure, atrial fibrillation, heart failure and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately impaired for daily decision-making, was always incontinent of bladder/bowel and had been receiving antibiotics. Review of the hospital History and Physical revised 02/16/25 revealed Resident #36 had been diagnosed and treated for sepsis, urinary tract infection (UTI) and pneumonia. Review of the Infection Control Log dated February 2025 revealed no evidence Resident #36…

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, policy review and interview, the facility failed to implement appropriate antibiotic stewardship. This affected one resident (#13) of three residents sampled for infections. The facility census was 87. Findings include: Medical record review revealed Resident #13 was admitted on [DATE] with diagnoses including left fibula and tibia fracture, heart failure, chronic kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms and urinary tract infection (UTI). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact for daily decision-making, did not utilize an indwelling catheter, was frequently incontinent of urine and had a UTI in the last 30 days. Review of the Progress Note dated 04/14/25 revealed Resident #13 complained of back pain and dysuria (difficulty urinating) over the weekend, and his urine was noted to be cloudy. Urinalysis sent for analysis and prophylaxis antibiotic Bactrim pending…

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

Based on observation, staff interview and facility policy review, the facility failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect all 93 residents in the facility. The census was 93. Findings include: Observation on 05/14/24 at 10:49 A.M. of the medication room refrigerator located on Maple Street and Main Street revealed an opened box with a used vial of tuberculin PPD five unit/0.1 milliliter(ml) one ml/vial with no date as to when it was opened. Interview on 05/14/24 at 10:50 A.M. with Licensed Practical Nurse (LPN) #299 verified there was no date as to when the tuberculin PPD vial was opened and stated, I know it was just opened yesterday as this is our last vial in the facility as there was a new admission and we do that for all new admission residents. Review of the facility policy titled Administering Medications, dated April 2019, revealed the policy stated when opening a multi-dose container, the date opened is recorded on the container.

Based on observation, staff interview, and facility policy review, the facility failed to ensure food was not expired and was stored appropriately. Additionally, the facility failed to ensure staff practiced proper hand hygiene when handling food. This had the potential to affect all 93 residents who resided in the facility. The facility identified all 93 residents received meals from the kitchen. The census was 93. Findings include: 1. During an initial tour of the kitchen on 05/13/24 from 11:40 A.M. to 11:50 A.M. with Dietary Manager (DM) #200, the following food items were observed in the refrigerator: one large half used container of salsa with a use by date of 05/03/24, one large unopened bag of brown, soggy shredded lettuce with a use by date of 05/09/24, one bag of fresh grapes which were opened, exposed to the air and undated, one unopened bag of pre-sliced potatoes with a use by date of 05/09/24, and one small partially used bottle of Red Hot hot sauce which was undated. Interview on 05/13/24 at 11:45 A.M. with DM #200 confirmed the above findings and DM #200 discarded the…

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

Based on review of the menu, review of the dietary spreadsheet, observations, staff interview, and review of facility policy, the facility failed to ensure the menu was followed. This affected 23 residents (Residents #1, #3, #6, #10, #13, #18, #22, #32, #36, #40, #41, #43, #45, #50, #59, #63, #69, #77, #81, #85, #153, #247, and #299) who were ordered a dysphagia advanced, mechanical soft, or pureed diet. The facility census was 93. Findings include: Review of the menu for the lunch meal on 05/15/24 revealed the meal consisted of a cheeseburger on a bun, lettuce and tomato, French fries, creamy coleslaw, and a cookie. Review of the dietary spreadsheet for the lunch meal on 05/15/24 revealed residents who received a dysphagia advanced diet should have received a sandwich with ground cheeseburger and a cup of shredded lettuce. Residents who received a mechanical soft diet should have received a number 10 scoop of ground pureed cheeseburger. Residents who received a pureed diet should have received a number 10 scoop of pureed cheeseburger. Interview on 05/15/24 at 10:35 A.M. with [NAME]…

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 THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a Self-Reported Incident, resident interview, staff interview, and facility policy review, the facility failed to ensure a resident was free from physical restraints. This affected one (Resident #56) out of one resident reviewed for abuse. The census was 93. Findings include: Review of Resident #56's medical record revealed Resident #56 was admitted to the facility on [DATE]. Resident #56's diagnoses included but were not limited to epilepsy, difficulty in walking, altered mental status, schizophrenia, cognitive communication deficit, dementia, insomnia, mood disorder, major depressive disorder, and anxiety disorder. Review of Resident #56's Minimum Data Set assessment, dated 04/09/24, revealed Resident #56 was cognitively intact. Review of the facility Self-Reported Incident (SRI) number 246866, dated 04/28/24, revealed Resident #56 alleged Licensed…

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 facility policy review, the facility failed to allow a resident who smoked, the opportunity to smoke. This affected one resident (Resident #86) of one resident reviewed for resident rights. Findings Include: Resident #86 was admitted to the facility on [DATE] with diagnoses including cerebral infarctions, dissection of vertebral artery, hemiplegia and hemiparesis, visual field defects, muscle weakness, tobacco use, hyperlipidemia, and acute ischemic heart disease. Resident #86 was discharged from the facility on 05/04/22. Review of Resident #86 medical records revealed a progress note dated 05/04/22 indicated the resident was to discharge from the facility because he was unable to smoke while in isolation. Review of Resident #86's medical record revealed no evidence the resident was assessed for smoking safely at the facility. The medical record revealed because he was not permitted to smoke while being in isolation, Resident #86 discharged from the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to provide adequate nail care and removal of facial hair for Resident #63. This affected one resident (Resident #63) out of two residents reviewed for activities of daily living. Findings Include: Review of the medical record for Resident #63 revealed an admission date of 12/28/20 with diagnoses including chronic obstructive pulmonary disorder, thrombocytopenia, anxiety and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had moderate cognitive impairment and required extensive assistance of two persons for personal hygiene and was totally dependent on staff for bathing. Review of the plan of care for activities of daily living revealed Resident #63 required assistance with grooming such as shaving and nail care. Review of the shower sheets for Resident #63 revealed he had a shower on 06/20/22, 06/23/22 and 06/27/22 with no documentation of fingernail care or shave.…

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 accurately monitor Resident #61's pressure ulcer. This affected one (Resident #61) out of four reviewed for pressure ulcers. Findings Include: Review of medical record revealed Resident #61 was admitted on [DATE] with diagnoses that included intraspinal abscess and granuloma, sepsis, and scoliosis. Review of Resident #61's admission assessment on 05/11/22 revealed Resident #61 had an area to right buttock that measured two centimeters (cm) long and 6.5 cm wide. Review of a Body assessment dated [DATE] revealed Resident #61 had a suspected deep tissue injury (SDTI) to the right buttock that measured two cm long and 6.5 cm wide. The Skin Integrity Report dated 05/12/22 revealed Resident #61 had a deep tissue injury (DTI) to right buttock that measured 6.5 cm long and two cm wide. Review of the plan of care dated 05/12/22 revealed Resident #61 had potential/actual impairment to skin integrity related to impaired mobility, medication use, fragile 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, staff interview, and facility policy review, the facility failed to provide adequate indication for use of as needed pain medications. This affected two residents (Residents #34 and #80) of five residents reviewed for unnecessary medications. Findings Include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, severe sepsis, cellulitis of left lower limb, hypomagnesemia, type II diabetes, atrial fibrillation, morbid obesity, cirrhosis of liver, hypothyroidism, chronic ischemic heart disease, fibromyalgia, anxiety disorder, hypoexmia, cystitis, myoclonus, osteoarthritis, hyperkalemia, anemia, hyperlipidemia, major depressive disorder, dysphagia, hypotension, and edema. Review of Resident #34's Minimum Data Set (MDS) 3.0 assessment, dated 06/23/22, revealed she was cognitively intact. Review of Resident #34 medical records revealed her current physician orders included oxycodone five milligrams (mg) every six hours as needed 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 interview, record review, and facility policy review, the facility failed to provide as needed dental service for Resident #73. This affected one resident (Resident #73) out of two residents reviewed for dental services. Findings Include: Review of the medical record for Resident #73 revealed an admission date of 05/16/22 with diagnoses including chronic respiratory failure, protein calorie malnutrition, lupus and chronic pain. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was cognitively intact with no behaviors. Resident #73 had no problems with chewing or swallowing. Resident #73 had frequent moderate pain and received scheduled and as needed pain medication. Review of the Medication Administration Record (MAR) for 06/2022 revealed Resident #73 received amoxicillin capsule (antibiotic used to treat dental infections) 500 milligrams (mg) by mouth every eight hours for abscess tooth for three days. Review of the Nurse Practitioner progress note dated 06/15/22…

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.