Liberty Retirement Community Of Lima INC

Based on medical record review, observations, staff interview, and policy review, the facility failed to provide activities to meet the resident's needs and cognitive capabilities. This affected one (#40) of three residents reviewed for activities. The facility census was 47.Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/29/20 with medical diagnoses of cerebral palsy (CP), profound intellectual disabilities, seizures, hypertension, and dysphagia. Review of an annual Minimum Data Set (MDS) assessment, dated 02/11/26, indicated Resident #40 had severe cognitive impairment and was dependent upon staff for all activities of daily living. Review of the medical record for Resident #40 revealed a care plan dated 01/23/24 that stated Resident #40 was dependent upon staff for emotional, physical, spiritual, creative, and community activities and social well-being related to CP and intellectual disabilities with a goal to maintain involvement in cognitive stimulation, and social activities as desired. Interventions included inviting 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 reviews, observation, and staff interviews, the facility failed to continually assess a surgical wound and schedule recommended follow up wound clinic appointments for Resident #02; failed to ensure accurate assessment of skin impairment and initiate treatment timely for a rash for Resident #10; and the facility failed to document the cause of wound injury/trauma area for Resident #51. This affected three (#02, #10, and #51) of four residents reviewed for skin assessments and treatments. The facility census was 47. Findings include: 1. Review of the medical record for Resident #02 revealed an admission date of 09/15/25, with medical diagnoses of acute osteomyelitis, diabetes mellitus (DM), peripheral vascular disease (PVD), congestive heart failure (CHF) and anemia. Review of the medical record revealed Resident #02 discharged to hospital on [DATE], readmitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], discharged to the hospital…

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 the medical record review, hospital report review, staff interview and policy reviews, the facility failed to ensure the necessary care and treatment was provided when a resident with a urinary catheter displayed symptoms of a urinary tract infection (UTI). This affected one (#51) out of two residents reviewed for care and treatment of urinary catheters. The facility census was 47.Findings include: Review of the medical record for Resident #51 revealed an admission date of 05/14/24 with medical diagnoses of diabetes mellitus, down's syndrome, Hirschsprung's disease, and obstructive and reflex uropathy. Review of the medical record revealed Resident #51 was discharged from the facility on 07/06/25 to hospital for evaluation of ongoing right abdominal pain and was admitted to the hospital with peptic ulcer disease, cholecystitis and UTI. Review of Resident #51's annual Minimum Data Set (MDS) assessment, dated 05/18/25, indicated Resident #51 had severe cognitive impairment and was dependent upon staff for…

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

Based on review of medical records and staff interview, the facility failed to ensure residents were assessed by a physician within the first 30 days after admission. This affected one (#28) of three residents reviewed for physician visits. The census was 47. Findings include:Review of Resident #28 medical record revealed an admission date of 06/25/25. Diagnoses listed included end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis.Review of a quarterly Minimum data Set (MDS) revealed Resident #28 was cognitively intact and received dialysis.Further review of Resident #28's medical record revealed the first documented physician assessment was on 12/10/25. Resident #28 had been assessed by a nurse practitioner (NP) and physician (PA) assistant prior to 12/10/25.Interview with MDS Nurse #201 on 03/16/26 at 2:15 P.M. confirmed Resident #28 had not been assessed within the first 30 days by a physician. The first time Resident #28 was assessed by a physician at the facility was 12/10/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to ensure an appropriate and timely response to the pharmacist drug regimen reviews. This affected two (#02 and #04) residents out of the five residents reviewed for pharmacy reviews. The facility census was 47.Findings include: 1. Review of the medical record for Resident #02 revealed an admission date of 09/15/25 with medical diagnoses of acute osteomyelitis, diabetes mellitus (DM), peripheral vascular disease (PVD), congestive heart failure (CHF) and anemia. Review of the medical record for Resident #02 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/20/26, which indicated Resident #02 was cognitively intact and was dependent upon staff for toileting, bathing, and transfers, and required substantial/maximum staff assistance with bed mobility. Review of the medical record for Resident #02 revealed a pharmacy recommendation dated 12/09/25 to adjust the administration time of the Doxycycline (antibiotic)…

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 medical records, staff interviews, and review of facility policy, the facility failed to have a justified use of an antibiotic. This affected two (#39and #40) of two residents reviewed for antibotics. The census was 47. Findings include: 1. Review of Resident #39's medical record revealed an admission date of 09/06/22. Diagnoses listed included hemiplegia, type two diabetes mellitus, bladder dysfunction, and hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact, had an indwelling urinary catheter, and had received an antibiotic. Review of physician orders revealed an order dated 07/23/25 for Cephalexin (antibiotic) oral tablet 500 milligrams (mg) give one tablet two times a day for prevention of infection. The end date was indefinite. A pharmacy note attached to the order was please clarify a stop date. Review of medication administration records (MAR) revealed Cephalexin was administered 07/24/25 through 03/11/26.…

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 residents were free from significant medications errors. This affected four (#3, #10, #51 and #53) residents out of five residents reviewed for medication administration. The facility census was 47.Findings include:1. Review of the medical record for Resident #10 revealed an admission date of 09/04/25 with medical diagnoses of cerebral infarction with left hemiplegia, mood disorder, hypertension (HTN) and epilepsy. Review of a quarterly MDS assessment, dated 12/31/25, which indicated Resident #10 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bathing and supervision with bed mobility and transfers.Review of a nurses note dated 03/02/26 at 7:02 P.M. stated Resident #10's significant other requested to take Resident #10 to Urgent Care due to excoriation under breasts and new rash covering extremities and torso. Review of a nurse's note dated 03/02/26 at 9:53…

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 interviews, and review of facility policy, the facility failed to ensure insulin multi-use vials were dated. This affected two residents' (#4 and #25) insulin vials observed in a medication cart. The facility also failed to ensure multi-dose insulin vials were discarded 28 days after the opened date. This affected one resident's (#12) insulin vial observed a medication cart. The facility also failed to ensure medications were stored in their original containers. This affected one medication cart of two observed. The census was 47.Findings include:Observation of the 600 hall medication cart on 03/16/26 at 10:31 A.M. revealed two multi-dose insulin vials were open and not dated. A 10 milliliter (ml) vial of Lantus (long-acting insulin) belonging to Resident #4 was opened and undated. A 10 ml vial of Novolog (rapid-acting insulin) belonging to Resident #25 was opened and undated. A 10 ml vial of Humalog (fast-acting insulin) for Resident #12 was dated as being opened on 02/14/26. Fifteen unidentified small round yellow pills were loose in the compartment…

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 policy review, the facility failed to notify the physician of an abnormal laboratory (lab) results timely. This affected one (#51) resident of one residents reviewed for laboratory test. The facility census was 47.Findings include:Review of the medical record for Resident #51 revealed an admission date of 05/14/24 with diagnoses including diabetes mellitus, Down's Syndrome, Hirschsprung's disease, and morbid obesity. Resident #51 discharged to the hospital on [DATE] and did not return to the facility. Review of an annual Minimum Data Set (MDS) assessment, dated 05/18/25,indicated Resident #51 had severe cognitive impairment and was dependent upon staff for activities of daily living. The MDS indicated Resident #51 had an indwelling catheter. Review of the medical record for Resident #51 revealed a physician order dated 06/11/25 for urinalysis (UA). Review of the medical record revealed a UA culture was completed on 06/14/25 and indicated the culture 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 medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents received dental services. This affected one (#34) of two residents reviewed for dental service. The facility census was 47.Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, heart failure, type two diabetes mellitus without complications, hypothyroidism, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment, dated 12/07/25, revealed the resident was cognitively intact. Review of the care plan, revised on 05/12/25, revealed Resident #34 had potential for oral/dental health problems due to poor oral hygiene. Interventions included to coordinate arrangements for dental care as needed/as ordered and monitor/document/report as needed any signs and symptoms of oral problems needing attention. Interview on 03/09/26 at 10:37 A.M. with Resident #34 revealed a few months after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, review of meal ticket, and review of facility policy revealed Resident #4 did not receive food items per preference. This affected one (#4) of four residents reviewed for nutrition. The facility census was 47. Findings include:Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included type two diabetes mellitus without complications, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and malignant neoplasm of unspecified female breast.Review of the Minimum Data Set (MDS) assessment, dated 01/08/26, revealed the resident was cognitively intact.Review of the meal ticket, dated 03/09/26, breakfast meal, verified Resident #4 was to receive two 2% milks, cranberry juice, and yogurt.Observation on 03/09/26 at approximately 7:45 A.M. revealed Resident #4 refused the meal tray due to not having requested items. Observation of the meal tray revealed no milk or cranberry juice was 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 review of the medical record, observation, staff interview, and review of facility policy, the facility failed to provide adaptive eating utensils. This affected one (#4) of one resident reviewed for adaptative equipment. The facility census was 47. Findings include:Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included type two diabetes mellitus without complications, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and malignant neoplasm of unspecified female breast.Review of the Minimum Data Set (MDS) assessment, dated 01/08/26, revealed the resident was cognitively intact and required set-up/clean up with eating.Review of the meal ticket, dated 03/09/26 breakfast meal, verified Resident #4 was to receive built-up utensils (1 each).Observation on 03/09/26 at approximately 7:45 A.M. revealed Resident #4 built-up utensils were not on the meal tray.Review of the meal ticket, dated 03/10/26 lunch meal, verified Resident #4 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, resident, family, and staff interview and review of facility policy, the facility failed to timely treat and assess the resident's pressure wounds. This affected two Residents (#10 and #12) of three residents reviewed for wounds. The facility census was 43. Findings include: 1) Review of medical record for Resident #10 revealed an admission date of 01/25/24. Diagnoses included end stage renal disease, congestive heart failure, diabetes mellitus type II, and chronic venous insufficiency. The resident was hospitalized on [DATE] and did not return. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had cognitive impairment. Resident #10 was dependent on staff for toileting hygiene, bed mobility, and transfers. Review of the care plan revealed potential for wounds or pressure ulcer development related to end stage renal disease, venous insufficiency and a past history of pressure ulcers. Interventions included to administer treatments as ordered and monitor…

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, pharmacy staff interview, facility staff interview, and review of facility policy, the facility failed to ensure residents were administered as physician ordered, resulting in a significant medication error. This affected one (Resident #10) of one resident reviewed for medication administration. The facility census was 43. Findings include: Review of medical record for Resident #10 revealed admission date of 01/25/24. The resident was admitted with diagnoses including end stage renal disease, congestive heart failure, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition. Review of the physician orders dated 11/01/24 revealed an order for Diltiazem (treats hypertension) extended release 180 milligrams (mg) daily. Review of the Medication Administration Record (MAR) from 11/01/24 to 11/07/24 revealed Diltiazem was administered on 11/01/24 and 11/06/24. It was not documented as administered on 11/02/24, 11/03/24,…

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, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were provided meals according to their preferences. This affected two residents (#20 and #21) of three residents reviewed for meal service. The facility census was 42. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 01/15/24. Diagnoses included cerebral infarction, dysphagia, type II diabetes, gout and convulsions. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #20 was moderately cognitively impaired. Resident #20 displayed no behaviors during the review period. Resident #20 had no weight changes at the time of the review. Review of Resident #20's care plan revised 10/21/24 revealed supports and interventions for self-care deficit, limited physical mobility, resistant to care, potential for verbal aggression, impaired…

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 records, facility policy and staff interviews, the facility failed to accurately document and treat wounds. This affected one (#10) of three residents reviewed. The facility census was 46. Findings include: Review of medical record for Resident #10 revealed admission date of 01/26/24. The resident was admitted with diagnoses including end stage renal disease, dialysis dependent, anemia, dementia without behaviors, and early onset Alzheimer's Disease. The resident was discharged on 06/17/24 to the hospital and did not return. The discharge return anticipated Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition. She required set up assistance for eating and was dependent on bed mobility, transfers and toileting hygiene. No pressure ulcer was documented. A care plan for potential for wounds or pressure development was initiated on 01/29/24 with interventions which included weekly treatment documentation to include measurement of each area of skins breakdown in width, length,…

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 records, facility policy and staff interviews, the facility failed to accurately document and treat pressure wounds. This affected one (#10) of three residents reviewed. The facility census was 46. Findings include: Review of medical record for Resident #10 revealed admission date of 01/26/24. The resident was admitted with diagnoses including end stage renal disease, dialysis dependent, anemia, dementia without behaviors, and early onset Alzheimer's Disease. The resident was discharged on 06/17/24 to the hospital and did not return. The discharge return anticipated Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition. She required set up assistance for eating and was dependent on bed mobility, transfers and toileting hygiene. No pressure ulcer was documented. A care plan for potential for wounds or pressure development was initiated on 01/29/24 with interventions which included weekly treatment documentation to include measurement of each area of skins breakdown in width,…

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 personnel files, review of facility documentation, and staff interviews, the facility failed to employ a qualified dietary manager. This affected all residents who received food from the kitchen. The facility identified two residents (#24 and #48) who did not receive food by mouth. The facility census was 51. Findings include: Review of personnel files revealed Dietary Manager #340 was hired on 06/09/23 and was promoted to the role of Dietary Manager on 04/21/24. Dietary Manager #340 did not have a Servesafe certification. Review of facility provided documentation revealed former Dietary Manager #380 was no longer employed at the facility effective 04/01/24. Interview on 05/05/24 at 12:42 P.M., with Dietary Manager #340 revealed she was in the process of taking the ServeSafe course with plans to complete it by the end of the month. Interview on 05/05/24 at 1:10 P.M., with Resident Care Coordinator #327 verified Dietary Manager #340 did not have the ServeSafe certification.

Based on observation, staff interview, review of the dishwasher manual, review of the dishwasher temperature log, and policies review, the facility failed to appropriately store food and ensure the dishwasher was sanitizing. This had the potential to affect all residents who received food from the kitchen. The facility identified two (#24 and #48) residents who do not receive food by mouth. The facility census was 51. Findings include: 1. Observation of the initial kitchen tour on 05/05/24 on 8:33 A.M., revealed a prepackage of frozen meatloaf thawing in the refrigerator with a sticky note on it that stated use for dinner on 04/25/24, hard boiled eggs to be discarded on 04/29/24, and bologna to be discarded on 04/29/24. There were also multiple boxes of keep frozen food such a pork links, meatloaf, and chicken fillets in the refrigerator. In the freezer there was an open to air bag of beef fritters and on the floor were three cracked eggs with no shells in different areas of the freezer. In the storage area were two large trays with unfrosted cupcakes covered with cardboard. 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 staff interviews, observations, review of Legionella Water Management Plan, and the review of policy, the facility failed to ensure procedures were followed for Legionella prevention and ensure staff properly transported soiled lines in common areas. This had the potential to affect all 51 residents. The census was 51. Findings include: 1. Review of the facility's, Legionella Water Management Plan updated 10/02/23 revealed control measures and monitoring included all sinks/showers/toilets would be visually checked daily, eye wash stations visually checked weekly and ice machines would be visually checked monthly. Upon request for records of the checks being completed, no records were provided. Interview on 05/07/24 at 4:22 P.M., with Maintenance Director #333 verified he was unable to provide documentation the visual checks had been completed. 2. Observation on 05/06/24 at 8:05 A.M., revealed State Tested Nursing Assistant (STNA) #377 carrying soiled linen in a bundle, in one hand, next to her body and a soiled brief in the other hand, down the hallway, into the soiled…

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, ombudsman interview, family interview, and policy review the facility failed to ensure pungent smells of urine did not permeate into common areas and dining room. This had the potential to affect all residents. The facility census was 51. Findings include: Observation on 05/06/24 at 7:25 A.M., of 300/400 hall nurses station/common area into the dining room revealed permeating urine odor with no residents in the area. Observation on 05/06/24 at 8:50 A.M., of 600 [NAME] hallway revealed permeating urine smell at the end of the hallway. Observation on 05/06/24 at 10:50 A.M., of 300/400 hall nurses station revealed urine odor was lightly detected. better at this time. When rounding the corner to the common area and dining room urine smell detected. Observation on 05/06/24 at 4:00 P.M., of 300/400 hall common area and dining room revealed faint urine odor. Observation on 05/07/24 at 7:24 A.M., revealed permeating urine odor still present in the 300/400 common area with no residents around in the area. On the way back through the 300/400 hall common…

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, resident diet list review, resident interview, resident representative interview, staff interviews, and review of policies, the facility failed to provide residents a dignified dining experience. This had the potential to affect all residents except 15 residents (#1, #3, #6, #18, #23, #24, #27, #30, #32, #34, #37, #41, #47 #48, and #198) who did not receive food by mouth and residents with a puree or mechanical soft diet. The facility census was 51. Findings include: Observation of the lunch meal on 05/05/24 revealed the meal included baked chicken, mashed potatoes, green beans, bread and butter, and fruit. Continued observation revealed the eating utensils residents received only included a fork and spoon. Residents were observed attempting to cut the chicken with a fork and spoon, shredding the chicken breast with a fork, or asking for assistance. Interview on 05/05/24 at 12:10 P.M., with an unidentified resident in the dining room revealed the chicken was hard to cut without a knife.…

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, resident family interview, staff interview, review of the activities calendar, review of the facility brochure, and review of policy, revealed the facility failed to provide appropriate and engaging activities in the memory care unit. This affected five residents (#20, #30, #36, #38, and #43) were reviewed with the potential to affect an additional five (#3, #24, #31, #32, and #34) residents in the memory care unit. The facility census was 51. Findings include: Review of the memory care activity calendar, dated 05/05/24 revealed two scheduled activities including at 12:00 P.M. root beer floats and 2:00 P.M. church. On 05/06/24, there were three scheduled activities including 9:00 A.M. Good Morning, 10:00 A.M. Shopping, and 3:00 P.M. Game Day (cards). On 05/07/24, three activities were scheduled including 9:00 A.M. Good Morning, 12:00 P.M. Book Swap, and 3:00 P.M. Book Read. Review of the facility brochure revealed Memory Care program is highlighted and stated 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, observation, staff interview, review of census sheet, review of the dietary spreadsheet, and policy review, the facility failed to ensure menus were followed including offering appropriate substitutions for 12 (#5, #21, #28, #27, #33, #40, #42, #47, #197, #198, #199, and #243) residents and serving sizes for 10 (#3, #20, #24, #30, #31, #32, #34, #36, #38, and #43) residents. The facility census was 51. Findings include: 1. Review of the 05/05/25 lunch meal revealed included baked chicken, mashed potatoes, green beans, bread and butter, and fruit. Observation on 05/05/24 at 12:31 P.M., of the lunch meal revealed the 300 and 400 hall resident cart meals included baked chicken, rice, pasta salad, and fruit. Observation revealed 12 (#5, #21, #28, #27, #33, #40, #42, #47, #197, #198, #199, and #243) residents were served the incorrect substitute. Interview on 05/05/24 at 12:35 P.M., with Dietary Aide #313 revealed they had run out of Italian green beans so she served left over pasta salad and they had also run out of mashed potatoes and determined to serve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and policy review, and facility policy the facility failed to reasonably accommodate a resident's requests. This affected one (#197) of one resident reviewed for choices. The census was 51. Findings include: Review of the medical record revealed Resident #197 was initially admitted on [DATE] with re-entry on 05/01/24. Diagnoses included other acute osteomyelitis left shoulder, neuromuscular dysfunction of bladder, bipolar disorder, quadriplegia, colostomy status, primary osteoarthritis, hypothyroidism, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 04/14/24, revealed the resident was cognitively intact. Resident #197 required substantial/maximum assistance for eating and dependent on staff for bed mobility. Review of the most recent care plan revealed the resident had a care plan for activities of daily living (ADL) care and required weight bearing assistance by staff to eat, the facility was to…

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

Based on observation, record review, policy review and staff interviews, the facility failed to ensure code status documentation was addressed timely. This affected one (#247) of 19 reviewed for advanced directives. The facility census was 51. Findings included: Review of medical record for Resident #247 revealed admission date of 04/29/24. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left breast, secondary malignant neoplasm of brain, depression and anxiety. The resident remained at the facility. Observation and interview on 05/05/24 at 3:36 P.M., with Registered Nurse (RN) #354 verified there was no code status information in Resident #247's hard chart. The side of the hard chart and paper behind the advance directive tab was labeled as Comfort Care (CC). There was an order for Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 04/29/24 in the electronic charting. RN #354 explained sometimes the resident information will not be placed in the hard chart until after therapy reviews the chart. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, nurse practitioner interview, staff interview, and policy review, the facility failed to implement interventions to prevent skin impairment timely for a resident with stage 4 pressure ulcers and ensure would measurements were completed upon readmission. This affected one (#197) of three residents reviewed for pressure ulcers. The facility census was 51. Findings include: Review of the medical record revealed Resident #197 was initially admitted on [DATE] with re-entry on 05/01/24. Diagnoses included other acute osteomyelitis left shoulder, neuromuscular dysfunction of bladder, bipolar disorder, quadriplegia, colostomy status, primary osteoarthritis, hypothyroidism, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 04/14/24, revealed the resident was cognitively intact. Resident #197 was dependent on staff for bed mobility, upper and lower body extremity dressing. Review of the most recent care plan revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview and policy review, the facility failed to provide adequate supervision for residents while they were smoking. This affected two (#1 and #6) of two residents reviewed for smoking. The facility identified five residents who smoke. The facility census was 51. Findings include: 1. Review of medical record for Resident #1 revealed admission date of 07/19/18, with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, seizures, hemiplegia affecting right dominant side, and major depressive disorder. Review of minimum data set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 which indicated cognitively intact. Resident #1 was dependent on staff for activities of daily living. Review of care plan dated 04/04/24 revealed Resident #1 is a smoker and often refuses to wear smoking apron. Interventions included the resident has been assessed and requires supervision while smoking, and smoking apron…

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 National Center for Biotechnology Information (NCBI) National Library of Medicine (NLM), the facility failed to monitor medication for potential side effects, toxicity and/or effectiveness. This affected one (#28) of five residents reviewed for unnecessary medications. The facility census was 51. Findings include: Review of medical record for Resident #28 revealed admission date of 07/13/23. The resident was admitted with diagnoses including Parkinsonism, chronic kidney disease, hyperlipidemia and type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 12 indicating impaired cognition. He required supervision for bed mobility, transfers, toileting and eating. Review of the physician orders revealed an order for Pravastatin (cholesterol) 40 milligrams (mg). Give one tablet at bedtime for hyperlipidemia. Record review of the physician orders for Resident #28…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure laboratory (lab) test were completed per physician orders. This affected three (#10, #17 and #26) of five residents reviewed for laboratory test. The facility census was 51. Findings include: 1. Review of medical record for Resident #10 revealed admission date of 11/25/12, with diagnoses including neuropathy, diabetes, cerebral infarction, major depressive disorder, chronic pain, hallucinations, chronic embolism and thrombosis of unspecified vein, and pure hypercholesterolemia. Review of minimum data set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 12 which indicated moderate cognitive impairment. Resident #10 required extensive assistance to full dependence on staff for activities of daily living. Review of current monthly physician orders for May 2024 revealed orders for Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Hepatic Panel, and Lipid Panel every three months (March, June,…

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, observation, review of the recipe, and staff interview, the facility failed to ensure pureed foods were made of appropriate consistency. This affected two (#24 and #48) residents who the facility identified as receiving a pureed diet. The census was 51. Findings include: Review of the lunch menu on 05/06/24 revealed the lunch included meatballs, noodles, mixed vegetables, and bread and butter. Review of the pureed meatloaf recipe revealed the recipe included meatloaf, beef base, hot water, and food thickener. Instructions included to prepare meatloaf in food processer, add broth and process until a smooth texture, add thickener and process briefly until mixed. Measurements of liquid and thickener may be adjusted to achieve desired texture. Observation on 05/06/24 at 10:50 A.M. revealed the facility substituted meatballs for meatloaf. Dietary Aide #321 placed two servings of meatloaf, two spoonsful of thickener, and an unknown amount of hot water (approximately half of a mug) in the blender. The meal was blended for approximately one to two minutes then…

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, review of the facility kitchen cleaning schedule checklist, and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect 47 residents in the facility. Resident #8 received no food by mouth and thus no food from the kitchen. The facility census was 48. Findings include: Observation on 12/29/23 at 7:22 A.M. of the facility kitchen found the three-sink dishwashing system was not in use. Food debris and a wet towel with brown areas and brown specks was found under it. In addition, a wet area with three or four wet towels and steam table tray was observed on the floor under a steam oven. Interview on 12/29/23 at 7:25 A.M. with Dietary Manager (DM) #157 verified there was a wet soiled towel under the dishwashing sink and wet towels and tray under the steam oven. DM #157 reported there had been a drain leak under the sink so the towel was there to absorb the water. DM #157 reported the drain leak had been repaired but they had not removed the towel. DM #157 also verified…

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, resident interview, staff interview and policy review, facility failed to ensure residents were properly supervised while smoking and smoking aprons were applied as required. This affected three (#1, #10, and #37) of three reviewed for smoking. The facility failed to sure a resident was transferred safely with a mechanical lift. This affected one (#48) of one resident reviewed for transfers. The facility census was 47. Findings include: 1. Review of medical record for Resident #1 revealed admission date 07/19/18, with diagnoses including multiple sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, dysphagia, chronic kidney disease, seizures, idiopathic progressive neuropathy, right foot drop, nicotine dependence cigarettes, major depressive disorder, hypertension, and anxiety. Review of Quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 02/02/23 revealed brief interview of mental status (BIMS) score of 13 which indicated cognitively…

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, resident interview and policy review, the facility failed to ensure a resident received showers per personal preference on shower days. This affected one (#13) of three residents reviewed for choices. The facility census was 47. Findings include: 1.Review of Medical Record for Resident #13 revealed admission date 01/25/22, with diagnoses including chronic respiratory failure with hypoxia, dysphagia, hyperlipidemia, hypertension, generalized anxiety disorder, chronic gout, depression, type two diabetes, and morbid obesity. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed brief interview of mental status (BIMS) score of 14 which indicated cognitively intact. Resident required extensive assistance for activities of daily living (ADL's). Review of Care Plan dated 12/08/22 for Resident #13 revealed the resident had an ADL self-care performance deficit related to chronic respiratory failure, dysphagia, obesity, hypertension, hypothyroidism, anxiety,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a resident was provided care and treatment to maintain foot health. This affected one (#35) of one resident reviewed for foot care. The facility census was 47. Findings include: Review of medical record for Resident #35 revealed admission date of 12/16/20, with diagnoses including schizoaffective disorder, bipolar type, anxiety, depression, and dementia with behavioral disturbances. The resident remains in the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely/never understood with severely impaired cognition. She required extensive one person assistance for bed mobility, transfers, eating toileting and personal hygiene. Review of the care plan for actual impairment to skin integrity related to left second toe with drainage and edema. Interventions included but were not limited to monitor and document size and treatment of skin injury. Report failure to heal, signs and symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure an antianxiety medication, which was ordered as needed (PRN), had an end date for use. The facility also failed to offer non-pharmacological interventions prior to administration of the PRN antianxiety medication. This affected one (#48) of the five residents reviewed for psychotropic medication use. The facility census was 47. Findings include: Review of the medical record for Resident #48 revealed an admission date of 03/28/23, with medical diagnoses of end stage renal disease (ESRD), chronic respiratory failure, diabetes mellitus, anxiety, and dependence upon dialysis. Review of the medical record for Resident #48 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #48 was cognitively intact and required extensive assist with bed mobility, dressing, toileting and was dependent upon staff for transfers. The MDS indicated Resident #48 received two days of antianxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure timely wound culture was obtained per physician orders. This affected one (#35) of one resident reviewed for laboratory test. The facility census was 47. Findings include: Review of medical record for Resident #35 revealed admission date of 12/16/20, with diagnoses including schizoaffective disorder, bipolar type, anxiety, depression, and dementia with behavioral disturbances. The resident remains in the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely/never understood with severely impaired cognition. She required extensive one person assistance for bed mobility, transfers, eating toileting and personal hygiene. Review of the care plan for actual impairment to skin integrity related to left second toe with drainage and edema. Interventions included but were not limited to monitor and document size and treatment of skin injury. Report failure to heal, signs and symptoms of infections…

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 interviews, the facility failed to assess and provide rehabilitation services as ordered. This affected one (#203) resident of the two residents reviewed for rehabilitation services. The facility census was 47. Findings included: Review of the medical record for Resident #203 revealed an admission date of 04/11/23, with medical diagnoses of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), malignant neoplasm of retromolar area, and anxiety. Review of the medical record revealed Resident #203's payer source was Medicaid. Review of the medical record for Resident #203 revealed a nursing admission assessment, dated 04/11/23, which stated Resident #203 was alert and oriented to person, place, time, and situation and was dependent upon staff for bed mobility, transfers, toileting, and extensive assist for dressing and grooming. Review of the medical record for Resident #203 revealed hospital discharge orders, dated 04/11/23, for…

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