Avenue At Lyndhurst

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #100 was free from neglect of necessary care and services to allow the resident to reach the highest practicable, physical and emotional well-being. This affected one resident (Resident #100) of five residents reviewed for abuse and neglect. The facility census was 88. Findings include:Review of Resident #100's medical record revealed Resident #100 was admitted on [DATE] with severe cognitive impairment, autistic disorder, moderate protein calorie malnutrition, immobility, bowel and bladder incontinence, and a history of skin issues.Review of Resident #100's admission Braden revealed a score was 9, indicating very high risk for pressure injuries. The resident required continuous enteral feeding via PEG tube and total assistance for all ADLs, including feeding, oral care, bathing, hygiene, and mobility.Review of Resident #100's medical record revealed a fungal rash to the right groin documented beginning 03/13/26, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility self-reported incident (SRI), policy review, and interviews, the facility failed to prevent the diversion of narcotics by staff. This affected one resident (Resident #73) of one resident reviewed for misappropriation. The facility census was 88.Findings include: Review of the medical record for Resident #73 revealed readmission to the facility on [DATE] with diagnosis including encounter for surgical aftercare following surgery on the digestive system. The resident had a physician's order for oxycodone (a narcotic given for pain control) 5 milligrams (mg) give one tablet by mouth every six hours as needed (PRN) for pain.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 received scheduled and PRN pain medications. The pain was described as almost constant, and frequently affected sleep with a level of eight on a zero to 10 pain scale with 10 being the worst.Review of the care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record reviews, staff interviews, and facility policy review, facility failed to implement person centered fall prevention interventions as outlined in the comprehensive care plans for Residents #10 and #82. This affected two residents (Residents #10 and #82) of 45 residents reviewed for care plans. The facility census was 88.Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including vascular dementia, pulmonary hypertension, and hemiplegia and hemiparesis following cerebral infraction affecting the left dominant side.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had a Staff Assessment for Mental Status (SAMS) that indicated he had short- and long-term memory problems, was severely impaired regarding tasks of daily life, had inattention, disorganized thinking and altered level of consciousness. Resident #10 had an impairment on one side of both the upper and lower extremities…

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, interviews, and policy review, the facility failed to ensure required care conferences were conducted and failed to verify resident and/or representative participation for Resident #77. This affected one resident (Resident #77) of 45 residents reviewed for care plans. The facility census was 88.Findings include: Medical record review for Resident #77 revealed an admission date of 02/11/26. Diagnoses included congestive heart failure, protein calorie malnutrition, chronic obstructive pulmonary disease, chronic kidney disease, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified Resident #77 as having severe cognitive impairment. Review of the care plan dated 05/20/26 showed Resident #77 had an alteration in bowel and bladder elimination, was at risk for falls, and required assistance with activities of daily living. The medical record did not contain any signed care conference attendance sheets or documentation verifying that 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 observations, resident record review, staff interviews, and facility policy review, the facility failed to implement adequate communication for non-English speaking residents. This affected two residents (Residents #50 and #65) of two residents reviewed for communication. The facility census was 88. Findings include: 1. Review of the medial record for Resident #50 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, asthma, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was sometimes understood and had a Brief Interview for Metal Status (BIMS) score of 0, that indicated short- and long-term condition impairment. Review of the MDS assessment revealed Resident #50 required some assistance from staff for activities of daily living (ADLs). Review of the care plan dated 05/20/26 revealed Resident #50 had a communication problem…

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 record review, the facility failed to administer medications to treat Parkinson's disease in a timely manner for Resident #87, and failed to ensure a timely orthopedic follow-up appointment was scheduled for Resident #99. This affected two residents (Resident #87 and Resident #99) of four residents reviewed for quality of care. The facility census was 88.Findings include: 1. A review of medical records for Resident #87 revealed the date of admission as 07/25/25 with diagnoses included Parkinson's disease with dyskinesia (difficulty moving). Resident #87's physician orders included Carbidopa-Levodopa (a prescription medication primarily used to treat Parkinson's disease and similar symptoms like tremors, stiffness, and slowness of movement) ER Oral Tablet Extended Release 50-200 MG (Carbidopa-Levodopa) give 1 tablet by mouth one time a day for tremors dated 12/03/25, Carbidopa-Levodopa Oral Tablet 25-250 Milligrams (MG), give 1 tablet by mouth in the morning for Parkinson's dated 02/06/26,…

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 record reviews, observations, interviews and facility policy review, the facility failed to provide timely and appropriate incontinence care for Residents #22 and #31. This affected two residents (Residents #22 and #31) of seven residents reviewed for incontinence care. The facility census was 88.Findings include:1. Review of the medical record for Resident #22 revealed the initial date of admission as 10/07/25 and a readmission date of 12/23/25. Diagnoses included overactive bladder. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed a brief interview for mental status with a score of 10 indicating Resident #22 had a mild cognitive deficit. The MDS also revealed Resident #22 was dependent on staff for toileting and was always incontinent of bladder and bowel.Review of the care plan dated 04/02/26 revealed Resident #22 had bowel and bladder incontinence. Interventions included checking and changing during care rounds and as needed. The care plan also revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, review of email and photographs provided by family, and policy review, the facility failed to ensure enteral tube feeding was provided as physician ordered for Resident #100 of two residents reviewed for enteral feedings. The affected one resident (Resident #100) of two residents reviewed for enteral feedings. The facility census was 88.Findings include:Review of the medical record for Resident #100 revealed an admission date of 03/13/26. Diagnoses included but were not limited to moderate protein-calorie malnutrition, autistic disorder, and gastrostomy status.Review of the 03/13/26 nursing admission assessment for Resident #100 revealed resident was a total assist for transfer, was non-weight bearing and nothing was indicated for communication. Resident #100 required total assistance of two staff for bathing, oral hygiene and transfers. Resident #100 was also noted to require one staff assistance for feeding.Review of the 03/20/26 physician order timed at 7:00 A.M.…

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

Based on observation, interview, record review, and review of facility policy, the facility failed to change a nebulizer mask (a mask used to distribute breathing medications by machine) in a timely manner for infection prevention measures. This affected one resident (Resident #85) of one resident reviewed for respiratory care. The facility identified 17 residents as utilizing nebulizers (#1, #7, #19, #22, #30, #33, #34, #35, #46, #47, #53, #66, #75, #77, #85, #94, and #107). The facility census was 88.Findings include:A review of medical record for Resident #85 revealed a date of admission of 03/13/26. Significant diagnoses included quadriplegia, acute and chronic respiratory failure with a low oxygen level, and unspecified injury to the sacral spinal cord.Review of Resident #85's physician orders included order for sodium chloride inhalation solution 3% one inhalation orally via nebulizer every 8 hours as needed for shortness of breath, albuterol sulfate nebulization solution 2.5 milligrams to 3 milliliters of solution inhale orally via nebulizer every 8 hours as needed 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 observation, interview and review of the facility policy, the facility failed to ensure adequate hand hygiene supplies were routinely available. This affected two residents (#14 and #27) of ten rooms observed. Facility census was 88. Findings include:Observation on 06/02/26 from 12:13 P.M. to 12:43 P.M. with Assistant Director of Property Management (ADPM) #416, Director of Maintenance (DOM) #343, Account Manager (AM) #414 and Senior District Manager (SDM) #415 revealed Resident #14 and Resident #27's hand sanitizer dispensers in the entryway of their rooms were empty and would not dispense alcohol based hand rub.Interviews with AM #414 and SDM #415 verified the findings at the time of observation and shared hand sanitizer was to be checked daily during room cleaning.Review of the undated facility policy, Seven Step Daily Washroom Cleaning, revealed staff were to be sure toilet paper, paper towels and soap dispensers were filled. Review of the undated facility policy, Five-Step Daily Room Cleaning, did not address restocking of room supplies.This deficiency represents…

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

Based on observations, interviews and facility policy review, the facility failed to ensure clean food service areas including opened food that was not labeled or dated. This had the potential to affect all residents who received meals from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86. Findings include:Initial tour of the kitchen on 08/18/25 from 8:24 A.M. through 8:40 A.M. revealed potato chips and white cake mix were not dated in the dry storage area. In the prep area, the slicer had dried food on the blade, and the mixer had dried batter on the back splash. In the reach-in refrigerator located under the prep table in the cook's area there was bacon, chicken noodle soup, and lima beans that were not labeled and dated. In the reach-in freezer, there was breaded chicken patties, chicken fingers, unbreaded chicken breasts, onion rings and French fries that were not labeled or dated. The findings were verified by the Administrator at the time of the observation. Review of the undated…

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, observations, interviews and facility policy review, the facility failed to ensure all call lights were within reach for residents who were dependent for activities of daily living. This affected four (Residents #5, #54, #89, #102) of 17 residents observed for accommodation of needs. In addition, the facility failed to ensure Resident #14 's tray table was in reach. This affected one (Resident #14) of 17 residents reviewed for accommodation of needs. The facility census was 86. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 06/23/23. Diagnoses included paranoid schizophrenia, muscle weakness, history of falls, and other abnormalities of gait and mobility. Review of the plan of care dated 12/22/24 noted Resident #5 was at risk for falls due to polyneuropathy, incontinent of bowel and bladder, and frequent falls. Interventions included encouraging use of the call light and keeping call light in reach. Review of the quarterly Minimum Data Set…

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 develop and implement comprehensive care plans. This affected four (Residents #1, #6, #7, and #39) of 38 residents reviewed for care plans. The facility census was 86. Findings include:1. Review of the medical record for Resident #39 revealed an admission date of 06/09/25 with diagnoses including quadriplegia, Guillain-Barre syndrome, generalized muscle weakness, and bilateral hand contractures. Review of the physician's orders dated 06/09/25 revealed Resident #39 had order for universal cuff (an assistive device for users with limited grip strength and dexterity to have more control of utensils) to hand with meals as tolerated and bilateral palm protectors (a device used for contractures to help prevent skin breakdown of the palm) to hands at night as tolerated. Review of the comprehensive care plan revealed no evidence of care planning to address Resident #39's adaptive equipment (universal cuff and palm protectors) needs. 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 record reviews, observations, interviews and facility policy review, the facility failed to provide timely incontinence care for dependent residents. This affected five (Residents #9, #15, #41, #69 and #84) of ten residents observed for incontinence care. The facility census was 86. Findings include:1. Review of the medical record for Resident #84 revealed an admission date of 01/06/24. Diagnoses included chronic kidney disease, encephalopathy, repeated falls and mild cognitive impairment. Review of the plan of care dated 03/01/25 noted Resident #84 was incontinent of bowel and bladder. Interventions included checking and changing on care rounds and as needed. Review of the plan of care dated 03/28/25 noted Resident #84 had a self-care deficit, limited mobility, and impaired cognition. Interventions included toileting assistance of one staff and transferring assistance of two staff with a mechanical lift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84…

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, interview and facility policy review, the facility failed to ensure residents at risk for falls were safe by implementing interventions written in the plan of care, appropriate call light response, and timely intermittent observations of residents. This affected one (Resident #65) of five residents reviewed for falls. The facility failed to ensure all residents requiring a mechanical lift for transfers were transferred safely. This affected one (Resident #65) of 34 residents who required a mechanical lift for transfers. The facility failed to provide care and services to prevent falls related to level of assistance. This affected two (Residents #18 and #39) of five residents reviewed for falls. The facility failed to ensure Resident #99 had a fall assessment and a pain assessment after a fall with minor injury. This affected one (Resident #99) of five residents reviewed for falls. The facility census was 86. Findings include:1. Review of the medical record for Resident #65…

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, observations, interviews and facility policy review, the facility failed to ensure all insulin pens were documented with resident name, opened and expired dates. The facility also failed to remove expired insulin pens in a timely manner. This affected eight (Residents #10, #24, #33, #40, #73, #78, #81, and #82) of 19 residents who required insulin. The facility census was 86. Findings include:1. Review of the medical record for Resident #10 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus with ketoacidosis without coma and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had impaired cognition. Review of the current physician orders revealed Resident #10 had orders for insulin glargine solution pen-injector dated [DATE] and insulin lispro solution pen-injector dated [DATE] daily. 2. Review of the medical record for Resident #24 revealed an admission date of [DATE]. Diagnoses included…

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

Based on observation, review of the meal spreadsheet, interview, and review of the facility policy, the facility failed to ensure accurate portions were served according to the menu diet spread sheet. This affected 22 (Residents #10, #14, #18, #29, #30, #37, #41, #42, #45, #46, #47, #51, #54, #56, #59, #66, #69, #73, #74, #78, #79, and #103) in the main dining room who were not on a pureed diet. The facility identified four (Residents #1, #48, #65, and #90) in the main dining room who received a pureed diet. This had the potential to affect all residents who received meals from the facility. The facility identified four (Residents #4, #19, #49, and #60) who received nothing by mouth (NPO). The facility census was 86. Findings include:Observation on 08/18/25 from 12:00 P.M. through 12:25 P.M. revealed residents were served by table. During the meal service, observation of the chicken and wild rice casserole revealed the portion appeared less than the spread sheet indicated. Interview on 08/18/25 at 12:23 P.M. with Resident #30 revealed that he was still hungry. Business Office…

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

Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This affected three (Residents #37, #666, and #103) and had the potential to affect all resident receiving food from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86. Findings include:Review of the undated facility mealtimes revealed breakfast was served from 7:00 A.M. to 8:45 A.M., lunch was served from 11:30 A.M. to 1:00 P.M., and dinner was served from 4:30 P.M. to 5:30 P.M. The identified order of serving was first dining room, assisted living, premium suites, front hall, middle hall and back hall. Observation of tray line on 08/18/25 at 12:25 P.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line, preferences were honored, condiments were available, and every tray had appropriate silverware including adaptive equipment. Observation on 08/18/25 revealed the food cart left the kitchen at 1:24 P.M. and was delivered to the back hall. Interview on 08/18/25…

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 Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training upon hire and/or annually to all staff who were employed at the facility. This had the potential to affect all 86 residents in the facility. Findings include:Review of the nursing in-service regarding behaviors on 05/06/25 revealed it included nursing staff but did not include housekeeping, dietary, or maintenance. Review of the facility's Facility assessment dated [DATE] included under staff training, education and competency training would be provided to all staff (beginning July 2023) about caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. Training included review of competencies and skills to provide patient care services that reflect the resident's goals. Review of the personnel record for Housekeeper #418 revealed he was contract staff with a hire date of 05/27/25 with no…

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

Based on medical record request review, email review, staff interview and facility policy review, the facility failed to fulfill a request for medical records in a timely manner. This affected one (Resident #100) of three residents reviewed for medical records requests. The facility census was 86. Findings include:Review of the medical record for former Resident #100 revealed an admission date of 10/07/24 and discharge date of 10/29/24. Resident #100 passed away while at the facility. Review of the medical records request dated 03/31/25 revealed a law firm representing Resident #100's personal representative requested a complete copy of all resident records in the possession of the facility for Resident #100. The request included a medical authorization form signed by Resident #100's administrator of estate and a court order for the release of the medical records and medical billing records. Review of the medical records request dated 05/12/25 revealed a second request was made for the medical records of Resident #100 by a law firm representing Resident #100's personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Ombudsman was notified of transfers for Residents #10 and #93, and the facility failed to ensure a transfer notice was issued for Resident #98. This affected three (Residents #10, #93, and #98) of three residents reviewed for hospitalization. The facility census was 86. Findings include:1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including acute kidney failure and multiple sclerosis. Review of the medical record revealed Resident #10 was sent to the hospital on [DATE] and was subsequently admitted to the hospital. Reviews of both the electronic and hard charts revealed no documented evidence that the Ombudsman was notified of the residents transfer to the hospital. Interview on 08/20/15 at 2:00 P.M. with Social Service Designee (SSD) #388 revealed that the Ombudsman was not notified that Resident #10 went to the hospital on [DATE]. 2. Review of the medical record 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 reviews and interviews, the facility failed to ensure medications were available for administration. This affected two (Residents #20 and #99) out of ten residents reviewed for medication administration. The facility census was 86. Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 08/01/22. Diagnoses included acute respiratory failure, visual loss of both eyes, dementia, peripheral vascular disease, osteoarthritis, and sarcoidosis of lung. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition. The resident required partial assistance with toileting and transferring. Review of the laboratory result for urinary analysis final result dated 07/28/25 at 3:28 P.M. revealed a positive result for nitrites and Proetus Mirabilis, a bacterium. Review of the physician progress note dated 07/30/25 at 5:09 P.M. revealed the urinary tract infection (UTI) laboratory results and medications were…

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, interview and facility policy review, the facility failed to ensure proper infection control with Resident #69 during incontinence care. This affected one (Resident #69) of one resident reviewed for incontinence care and had the potential to affect six additional (Residents #1, #22, #42, #55, #59, and #77) whom required incontinence care on the Certified Nursing Assistant's (CNA) #365's assignment. The facility census was 86. Findings include:Review of the medical record for Resident #69 revealed an admission date of 09/19/23. Diagnoses included type II diabetes, Alzheimer's disease, encephalopathy, morbid obesity, overactive bladder and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had impaired cognition. The resident was dependent on staff for eating, toileting, showering and dressing. Resident #69 was incontinent of bowel and bladder. Observation on 08/20/25 at 9:20 A.M. of incontinence care with Resident #69,…

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 and interview the facility failed to ensure chart room that contained residents private information were secured. This had the potential to affect all residents residing in facility. The facility census was 100. Findings include: Tour on 01/21/25 at 10:42 A.M. with Director of Nursing (DON) revealed 3 out of 4 doors to the facility's chart rooms had tape over the locks and the rooms were not secured. Each room contained the resident's hard chart with access to various components of the medical record. The DON confirmed the tape on the door and stated chart rooms were to be locked at all times, and removed the tape during tour. Observation on 01/27/25 at 6:52 A.M. revealed a chart room located on the 300 hall that had a wheelchair leg placed in the doorway leaving the door propped open. Interview with Licensed Practical Nurse (LPN) #834 at the time of observation confirmed the door was propped open when she arrived to start her shift on 01/26/25 at 7:00 P.M. LPN #834 stated the doors to the chart rooms were to remain secured at all times. This deficiency…

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, resident interviews, staff interviews, review of time punch details, daily staffing sheets and schedules, review of the facility assessment, and facility policy review, the facility failed to ensure adequate staffing levels to meet the needs of the residents. This affected all residents residing in the facility. The facility census was 100. Finding include: 1. Review of the daily staffing sheet dated 01/21/25 revealed the facility had 7 Certified Nurses Assistants (CNAs) scheduled for the 1st shift. Review of the daily staffing sheet revealed each CNA had designated rooms to provide care for. Review of the daily staffing sheet revealed CNA #838 was assigned to fifteen residents (#7, #11, #13, #20, #24, #29, #32, #35, #36, #38, #50, #66, #70, #77, #98), CNA #824 was assigned sixteen residents (#15, #18, #26, #27, #28, #49, #61, #67, #71, #72, #80, #82, #89, #91, #94, #100), CNA #885 was fourteen residents (#1, #6, #9, #17, #25, #30, #42, #44, #45, #54, #62, #78, #83, #92), CNA #878 was…

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

Based on observation, resident interviews, staff interviews, facility policy review, and return demonstration of a test tray, the facility failed to serve hot, palatable meals. This affected all 100 residents as the facility did not identify any residents that were solely not receiving food by mouth (NPO). Findings include: Interview on 01/21/25 at 7:51 A.M. with Resident #52 revealed the food needed to be improved and was often cold. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed she often did not want her breakfast because it was cold and always needed rewarmed. Interview on 01/21/25 at 9:38 A.M. with Resident #3 revealed the facility food was bad. Interview and observation at 9:44 A.M. revealed Resident #54 call light was activated. Resident #54 revealed her food was cold and needed warmed up. Resident #54 revealed she did not like eating cold food. Interview on 01/21/25 at 10:06 A.M. with Resident #62 revealed the facility food was a joke. Observation on 01/23/25 at 7:20 A.M. of the kitchen breakfast meal preparation with Dietary Manager (DM) #908 revealed 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 observation, resident interviews, staff interviews, and review of facility mealtimes, revealed the facility failed to ensure meals were served in a timely manner. This affected all 100 residents as the facility did not identify any residents that were solely not receiving food by mouth (NPO). The facility census was 100. Findings include: Interview on 01/21/25 at 7:51 A.M. with Resident #52 revealed the facility food could be improved. Resident #52 revealed the food was always served late and cold. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed she had not received her breakfast yet. Resident #54 revealed the food was always cold and needed to be warmed up. Observation on 01/21/25 at 9:10 A.M. revealed the breakfast cart arrived to the 200-Hall unit. Observation and interview on 01/22/25 at 9:31 A.M. revealed Resident #77 did not have a breakfast tray. Certified Nurse Assistant (CNA) #862 confirmed and verified Resident #77 was still without a breakfast tray. Observation and interview on 01/22/25 at 9:34 A.M. revealed Resident #115 was seated in her…

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 and interview the facility failed to ensure adequate amounts of supplies were available to provide resident care. This had the potential to affect all residents residing in the facility. The facility census was 100. Findings include: Observation of clean linen closet on the 200 hall on 01/21/25 at 9:45 A.M. revealed no towels or washcloths and 1 package of disposable incontinence briefs. Observation was confirmed by Certified Nursing Assistant (CNA) #824 and CNA #824 stated she often had to go to other units to look for items and stated there had been times she had not had linens for a few hours after the start of her shift at 7:00 A.M. Interview on 01/22/25 at 8:38 A.M. with CNA #861 revealed there had been many times she did not have supplies to provide incontinence care. Interview on 01/27/25 at 12:59 P.M. with Resident #27's daughter revealed on 01/26/25 at 1:16 P.M. she had sent a text message to the Director of Nursing (DON) to inform her of the lack of incontinence briefs for Resident #27. Resident #27's daughter stated the DON had not responded to her…

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

Based on record review and interview, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all residents. Findings include: Review of the STNA assignments dated 01/07/25 through 02/05/25 revealed one nurse was assigned to the SNF (Skilled Nursing Facility) premium nursing unit and one to two Certified Nursing Assistant's (CNA)'s were assigned to the SNF premium nursing unit. The schedule did not specify which nurse and aide were assigned to care for residents in the attached Assisted Living (AL) area. Interview on 02/04/25 at 2:40 P.M. of the Administrator revealed the Skilled Nursing Facility (SNF) and the Assisted Living (AL) area did not have separate schedules for staff assignments. The Administrator stated the SNF and AL used the same schedule. The Administrator stated the nurse and aides assigned to the SNF premium nursing unit were the same nurse and aides who cared for residents in the AL area. The Administrator confirmed 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 employee file review and interview, the facility failed to ensure staff were trained as required. This had the potential to affect all 100 residents residing at the facility. Findings include: Review of the employee file for Certified Nursing Assistant (CNA) #823 on 01/29/25 at 10:30 A.M. with Human Resource Director #871 revealed an employee start date of 10/10/24. Review of the general orientation check list dated 10/10/24 for CNA #824 revealed it was incomplete with numerous sections not indicated as checked off as complete. The orientation checklist revealed various admissions/marketing, dietary, social services, administration, therapy, and nursing areas were not indicated as being checked off. Areas which were not checked off as complete included but were not limited to infection control, dementia and memory care training, wound care, incident/accident reporting, restorative nursing, transfer techniques, Hoyer procedures and enhanced barrier precautions. Review of the employee file for CNA #885 on 01/29/25 at 10:35 A.M. with Human Resource Director #871 revealed 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, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were treated with dignity and respect. This affected four residents (#50, #59, #70, and #71) of four residents reviewed for dignity and respect. The facility census was 100. Findings include: 1. Review of Resident #50's medical records revealed an admission date of 11/27/24. Diagnoses included paraplegia and bladder dysfunction. Review of the care plan revised 01/22/25 revealed Resident #50 had an indwelling urinary catheter. Interventions included ensure Resident #50 had a privacy bag on catheter. Observation on 01/21/25 at 3:02 P.M. revealed Resident #50 was in a wheelchair in the entrance foyer and Resident #50's urinary catheter drainage bag was not covered by a privacy bag. The Administrator confirmed the finding at the time of observation. 2. Review of Resident #70's medical records revealed an admission date of 07/11/24. Diagnoses included urinary retention and bladder…

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, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure the resident environment was maintained in a clean and sanitary manner, and failed to ensure water temperatures were at a comfortable level. This affected seven residents (#6, #29, #42, #49, #70, #82, and #83) of seven reviewed for physical environment. The facility census was 100. Findings include: 1. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included schizophrenia, syncope and collapse, and hypertensive heart disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 7 that indicated he was alert with cognition impairment. Review of the MDS assessment revealed Resident #82 required assistance from staff for Activities of Daily Living (ADLs). Review of the care plan dated 01/17/24 revealed 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.

Based on interview, policy review, grievance log review, and personnel file review the facility failed to ensure resident concerns were addressed. This affected four residents (Resident #9, Resident #27, Resident #61, and Resident #73) and had the potential to affect all 100 residents residing in the facility. Findings include: Telephone interview on 01/21/25 at 11:26 A.M. with Resident #73's family revealed she had a camera placed in Resident #73's room due to care concerns. Resident #73's family stated she had observed Resident #73 had not received care for several hours and stated she had emailed the Administrator and had sent text messages to the Director of Nursing (DON) to express her concerns. Resident #73's family stated the issues had been addressed, however it had not lasted long and the same issues had continued to occur. Telephone interview on 01/21/25 at 12:50 P.M. with Resident #9' family revealed she had expressed concerns to the DON related to Resident #9's care as well as the cleanliness of her room and stated the DON had not addressed her concerns and the issues…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interview, and facility policy review, the facility failed to ensure resident care plans were up-to-date and reviewed on a quarterly basis as required. This affected four residents (#9, #26, #44, #54) of four residents reviewed for care planning. The facility census was 100. Findings include: 1. Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee, hypertensive heart disease without heart failure, and major depressive disorder. Review of the quarterly, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she cognitively intact. Review of the MDS assessment revealed Resident #44 required assistance from staff for Activities of Daily Living (ADLs). Review of the physician orders dated 01/21/25 revealed Resident #44 had an order for droplet isolation for COVID-19 with all…

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, medical record review, review of hospital records, and facility policy review, the facility failed to timely implement a physician-ordered treatment to a vascular wound upon admission. This affected one (Resident #77) of three residents reviewed for wound care management. Additionally, the facility failed to ensure resident call lights were answered and care provided in a timely manner. This affected four (Residents #17, #25, #26, and #44) of four residents reviewed for call lights. The facility census was 100. Findings include: 1. Review of Resident #77's medical records revealed an admission date of 01/18/25. Diagnoses included diabetes, muscle weakness, and difficulty walking. Review of Resident #77's pre-admission hospital records, dated 01/07/25 through 01/18/25 revealed the resident was hospitalized for care and treatment of a left foot arterial (vascular wound) ulcer to the top of the left foot and ankle. The records noted the resident had significant pain to the left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, facility policy review, the facility failed to adequately monitor resident nutritional status by not obtaining consistent weights per physician orders. This affected four residents (Resident #26, #54, #66, and #101) of eight residents reviewed for weights. This had the potential to affect all 100 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 02/11/23. Diagnoses included but were not limited to hemiplegia and hemiparesis, morbid obesity, unilateral osteoarthritis. Review of Resident #26's Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #26 required supervision for meals. Review of physician orders for Resident #26 revealed no active order for weight monitoring. Review of the electronic medical record 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 record review, staff interview, and review of facility policy, the facility failed to ensure residents' were timely administered medications and were free from significant medication errors. This affected five (Residents #26, #27, #61, #77, and #115) of five resident records reviewed for medication administration. The facility census was 100. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 02/11/23. Medical diagnoses included hemiplegia and hemiparesis, morbid obesity, and osteoarthritis. Review of Resident #26's Medication Administration Record (MAR) for January 2025 revealed the resident had orders for the following morning medications daily at 8:00 A.M.: a. Sennosides 8.6 milligram (mg) two tablets for bowel maintenance b. Gabapentin 300 mg one capsule for neuropathy c. Losartan potassium 25 mg one tablet for hypertension d. Levetiracetam 500 mg one tablet for convulsions e. Potassium chloride extended release (ER) 10 milliequivalents (mEq) one tablet f. Apixaban (blood thinner) 5 mg one tablet for atrial fibrillation g.…

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, resident record review, staff interview, and facility policy review, the facility failed to ensure resident dietary preferences were maintained. This affected five residents (#25, #26, #28, #33, and #82) of five reviewed for dietary preferences. The facility census was 100. Findings include: 1. Review of the medical record for Resident #28 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cerebral infarction, and atrial fibrillation. Review of the quarterly, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #28 was dependent on staff for Activities of Daily Living (ADLs). Review of the care plan dated 07/03/23 revealed Resident #28 had potential for altered nutrition related to hemiplegia, dementia, and morbid obesity with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident records were maintained in an accurate manner and contained the assessments and services provided. This affected seven residents (#6, #9, #49, #54, #77, #82, #83) of seven reviewed for accurate medical records. The facility census was 100. Findings include: 1. Review of the medical record for Resident #6 revealed she admitted to the facility on [DATE] with diagnoses that included sepsis, Alzheimer's disease, and muscle weakness. Review of the physician orders dated 12/18/24 revealed Resident #6 required two-person assist for transfers. Review of the care plan dated 12/19/24 revealed Resident #6 had a self-care deficit with interventions that included assistance of one for bathing. Review of the medical record for Resident #83 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dementia, and epilepsy. Review of the care plan dated 07/03/23 revealed Resident #83 had a self-care deficit with…

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

Based on observations, resident interviews, staff interviews, and facility policy review, the facility failed to ensure the resident environment was kept in a clean and sanitary manner. This had the potential to affect all 100 residents residing in the facility. Findings include: Observation on 01/21/25 at 7:52 A.M. revealed multiple old, dirty dinner trays sitting on the ledge of the common area on the 200-Hall Unit, adjacent to Resident #80 room. Observation on 01/21/25 at 7:53 A.M. revealed multiple open and used staff drinks situated at the nurses station located on the 200-Hall Unit. Observation and interview on 01/22/25 at 5:45 A.M. revealed dirty dinner dishes sitting on the ledge of the common area on the 200-Hall Unit, adjacent to Resident #62 room. Certified Nurse Assistant (CNA) #883 revealed she wasn't aware of who placed the dishes there. CNA #883 revealed staff should have taken them away after the dinner meal. CNA #883 confirmed and verified the dirty dinner trays and dishes located on the 200-Hall Unit at the time of the observations. Observation and 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 review of camera footage, medical record review, interview, and review of facility policy, the facility failed to ensure call lights were within reach of residents. This affected one resident (#61) out of five observed for call lights. The facility census was 100. Findings include: Review of Resident #61's medical records revealed an admission date of 08/21/24. Diagnoses included falls, chronic heart failure and chronic obstructive pulmonary disease. Review of the care plan dated 05/08/24 revealed Resident #61's room had continuous video monitoring. Resident #61 had noted self-care deficits. Interventions included to encourage Resident #61 to use call bell for assistance. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition. Resident #61 was dependent with toileting and required maximum assistance with bathing and personal hygiene. Interview on 01/21/25 at 1:41 P.M. with Resident #61's wife revealed on 12/26/24 she had reviewed camera footage that had shown…

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, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), and review of facility policy, the facility failed to timely report an injury of unknown origin to the State Agency as required. This affected one resident (#64) of three residents reviewed for self reported incidents. The facility census was 100. Findings include: Review of Resident #64's medical record revealed an admission date of 01/09/25. Diagnoses included muscle weakness, difficulty walking and dementia. Review of the care plan dated 01/09/25 revealed Resident #64 was at risk for falls. Interventions included maintain a safe and clutter free environment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had intact cognition and required moderate assistance with sit-to-stand transfers and bed-to-chair transfers. Review of a progress note dated 01/20/25 timed 10:16 P.M. with a created date of 01/22/25 at 11:26 A.M. authored by Registered Nurse (RN) #801…

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, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were provided assistance with meals. This affected two residents (#26 and #71) of three residents reviewed for meal assistance. The facility census was 100. Findings include: 1. Review of the medical record for Resident #71 revealed she was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis, dementia, and hypertensive heart disease with heart failure. Review of the quarterly Staff Assessment for Mental Status (SAMS) assessment dated [DATE] revealed Resident #71 had short and long-term memory loss and was severely impaired regarding tasks of daily life. Review of the SAMS assessment revealed Resident #71 was dependent on staff for Activities of Daily Living (ADLs). Review of the physician orders dated 12/10/24 revealed Resident #71 had an order for a regular diet, pureed texture with thin consistency liquids. Review of the physician orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure Resident #17's newly-identified pressure ulcer was timely assessed and had a treatment implemented. This affected one (Resident #17) of three residents reviewed for wounds. The facility census was 100. Findings include: Review of Resident #17's medical record revealed an admission date of 04/13/22 with medical diagnoses including stroke with right-sided weakness, aphasia (difficulty speaking) and falls. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely or never understood. Resident #17's cognition was not assessed on the assessment. Resident #17 was noted to be occasionally incontinent of bowel and bladder. She required moderate assistance with toileting and maximum assistance with bathing and personal hygiene. Review of Resident #17's care plan dated as revised 01/18/25 revealed the resident was at risk for altered skin integrity due to incontinence…

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 record review, the facility failed to ensure a hand splint was re-ordered and applied as requested. This affected one (Resident #26) of three residents reviewed for range of motion. The facility census was 100. Findings include: Review of the medical record for Resident #26 revealed an admission date of 02/11/23. Diagnoses included but were not limited to hemiplegia and hemiparesis, morbid obesity, and unilateral osteoarthritis. Resident #26 was recorded as being hospitalized from [DATE] to 07/10/24. Review of the physician order dated 08/15/23 revealed and order for Resident #26 to wear left hand resting splint daily for six hours as tolerated. The order was noted to be discontinued on 07/10/24. Review of Resident #26's Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #26 required…

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 review of facility policy, the facility failed to ensure Resident #97 and #110 had accurate and thorough fall investigations completed, and failed to ensure admission nursing care plans with individualized fall prevention interventions were implemented. This affected two (Residents #110 and #97) of three residents reviewed for falls. Additionally, the facility failed to ensure only clinical and trained staff members provided assistance with transfers. This affected one (Resident #115) of three residents observed for safe transfers. The facility census was 100. Findings include: 1. Review of the facility incident log from 11/22/24 through 01/22/25 did not revealed no indication Resident #110 had experienced a fall on 01/14/25. Review of an updated facility incident log from 11/22/24 through 01/22/25 revealed Resident #110 had a witnessed fall on 01/14/25 at 9:21 P.M. Review of Resident #110's medical record revealed an admission date of 01/14/25 and diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provided timely and appropriate incontinence care for dependent residents. This affected three residents (#26, #49 and #54) of three residents reviewed for incontinence care. The facility census was 100. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 02/11/23. Diagnoses included stroke with left sided weakness, overactive bladder and muscle weakness. Review of Resident #26's care plan revised 11/01/24 revealed Resident #26 was incontinent of bowel and bladder. Interventions included check for incontinence every two hours. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 required maximum assistance with toileting and bathing. Resident #26 was incontinent of bowel and bladder. Observation on 01/21/25 at 7:47 A.M. revealed Resident #26's call light was active. Interview with Resident #26 at time of observation…

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 interview, review of photographs, and review of the facility policy, the facility failed to ensure medications were not left unattended in residents' room. This affected three residents (#27, #61 and #115) of five residents reviewed for . The facility census was 100. Findings include: 1. Interview on 01/22/25 at 1:34 P.M. with Resident #27's daughter revealed the resident's morning medications had been administered in the afternoon on 01/21/25. When she arrived at the facility on the afternoon of 01/21/25, she observed two cups of medications in Resident #27's room containing various pills. Resident #27's daughter stated she had taken a photo of the medication cups on 01/21/25 at 3:16 P.M. The photograph was provided at the time of interview and two cups of medications were observed in the photo. 2. Interview on 01/27/25 at 11:55 A.M. with Registered Nurse (RN) #874 revealed on 01/24/25 sometime before lunch (couldn't recall exact time), Resident #115's daughter had informed her that Resident #115 had unknown medications in her oatmeal. RN #874 stated she had went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #64's diagnostic test for a suspected injury was ordered, reported, and treatment was initiated timely. This affected one resident (Resident #64) out of three residents reviewed for diagnostic testing. The facility census was 100. Findings include: Review of Resident #64's medical record revealed an admission date of 01/09/25 and diagnoses included acute embolism and thrombosis of unspecified deep veins of the left lower extremity, encephalopathy and type two diabetes mellitus without complications. Review of Resident #64's care plan dated 01/09/25 included Resident #64 was a high risk for falls related to deconditioning, gait and balance problems and history of falls. Resident #64 would be free of falls through the review date. Interventions included to follow the facility fall protocol; anticipate and meet Resident #64's needs. Review of Resident #64's MDS admission assessment dated [DATE]…

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 record review, and staff interview, the facility failed to ensure resident meals were served in the proper, safe form. This affected one resident (#60) of one reviewed for therapeutic diets. The facility census was 100. Findings include: Review of the medical record for Resident #60 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes, and hypertension. Review of the quarterly Staff Assessment for Mental Status (SAMS) assessment dated [DATE], revealed Resident #60 had a short and long-term memory problem and was severely impaired regarding tasks of daily life with inattention that fluctuated. Resident #60 was dependent on staff for Activities of Daily Living (ADLs) Review of the care plan dated 08/17/23 revealed Resident #60 had potential for altered nutrition with interventions that included providing and serving prescribed diet as ordered by the physician. Review of the physician orders dated 05/23/24 revealed Resident #60 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, and staff interview, the facility failed to ensure residents were provided with the appropriate assistive devices for meals. This affected one resident (#60) of one reviewed for assistive devices. The facility census was 100. Findings include: Review of the medical record for Resident #60 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes, and hypertension. Review of the quarterly Staff Assessment for Mental Status (SAMS) assessment dated [DATE], revealed Resident #60 had a short and long-term memory problem and was severely impaired regarding tasks of daily life with inattention that fluctuated. Resident #60 was dependent on staff for Activities of Daily Living (ADLs) Review of the care plan dated 08/17/23 revealed Resident #60 had potential for altered nutrition with interventions that included utilizing a red divided plate as an assistive device for meals. Review of the physician orders dated 05/23/24…

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 observations, record review, staff interviews, and facility policy review, the facility failed to ensure facility staff followed infection control policies, protocols, and failed to ensure residents were care planned for infection control. This affected two residents (#9 and #44) of three reviewed for infection control. The facility census was 100. Findings include: 1. Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee, hypertensive heart disease without heart failure, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 13 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #44 required assistance from staff for Activities of Daily Living (ADLs). Review of the progress note dated 01/20/25 at 2:54…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure residents were regularly screened for risk of falls. This affected three residents (#15, #57, and #61) of four residents reviewed for falls. The facility census was 83. Findings include: 1. Record review of Resident #15 on 07/30/24 revealed she was admitted on [DATE] with diagnoses including diabetes, muscle weakness, and venous insufficiency. Review of her assessments revealed her last fall risk assessment was done 01/28/24 and identified her to not be at risk for falls. She had no documented falls in the last three months. 2. Record review of Resident #57 on 07/30/24 revealed she was admitted on [DATE] with diagnoses including Alzheimer's dementia, diabetes, obesity, and unspecific difficulty walking. Review of her assessments revealed her last fall risk assessment was done 11/05/23 and identified her to be at risk for falls. She had no documented falls in the last three months. 3. Record review of Resident #61 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure wound care was ordered and documented according to nurse practitioner orders. This affected one resident (#15) of three residents reviewed for wound care. The facility census was 83. Findings include: Record review of Resident #15 revealed she was admitted [DATE] with diagnoses including a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) and diabetes. She had an as-needed order dated 07/19/24 for wound care, but no scheduled time or days when wound care was to be done. Review of her treatment administration record (TAR) revealed no wound care procedures were documented as completed in 07/2024. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had mild or no cognitive impairment and had a stage III pressure sore…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of court documents, review of the Statement of Expert Evaluation, review of a police report, and facility policy review, the facility failed to prevent an unauthorized leave of absence (LOA) and subsequent discharge of Resident #78 who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS). This affected one resident (#78) of three residents who were reviewed for discharge. The facility census was 76. Findings Include: Review of the medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of a sworn affidavit in Resident #78 medical records dated 01/09/24 completed by an APS social worker revealed Resident #78 suffers from dementia and is frail and unsteady on her feet. It also revealed Resident #78 was unable to state what to do in an emergency. Impairments of short- and long-term memory were noted. The home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of hospital records, review of a police report, and facility policy review, the facility failed to permit Resident #78, who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS), to return to the facility after an unauthorized leave of absence (LOA) with family. This affected one resident (#78) of three residents reviewed for discharge. The facility census was 76. Findings Include: A review of medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of hospital record reviews revealed an emergency room record dated 01/19/24 revealed Resident #78 was there for evaluation and guardianship. There were social and financial concerns. A psychiatry evaluation dated 01/22/24 while Resident #78 was in the hospital revealed Resident #78 lacked capacity to make own medical decisions, had moderate cognitive and memory…

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 food was served in a sanitary manner and food was stored and dated properly. This had the potential to affect 67 of 69 residents receiving food from the kitchen. The facility identified Residents #63 and #73 as not receiving food from the kitchen. The facility census was 69. Findings include: An initial tour of the kitchen was conducted on 01/16/24 between 9:30 A.M. and 10:35 A.M. with Dietary Manager (DM) #814. The following was observed and verified at the time of observation. In the dry storage area, one bag of hot cocoa, one bag of brown sugar, and one bag of biscuit mix was undated, and one bag of food thickener was open to air, unsealed. In the walk-in fridge, a container of cooked rice was open to air. In the walk-in freezer, one bag of hash browns, one box of frozen chicken, one bag of celery, and one bag of green peppers were open to air and undated. During the follow-up tour of the kitchen on 01/16/24 at 11:29 A.M. at the time of tray line, DM #814 was observed checking 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 observation, staff interview, and facility policy review, the facility failed to ensure temperatures in the main dining room were kept at a comfortable level. This had the potential to affect seventeen residents (#5, #7, #15, #18, #19, #22, #23, #24, #27, #31, #33, #37, #39, #41, #47, #48, #377) the facility identified as residents who ate meals in the main dining room. The facility census was 69. Findings include: Observation on 01/17/24 at 4:36 P.M. in the main dining room, during the dinner meal, revealed a thermostat located on the wall adjacent to the windows. The thermostat was set to 68 degrees Fahrenheit (F) with a current temperature reading of 66 degrees F. Interviews on 01/17/24 at 4:38 P.M. with Residents #18, #23 and #31 revealed it was cold and sometimes uncomfortable while eating due to the the dining room not being warm. Observation and interview on 01/17/24 at 4:39 P.M. revealed Bookkeeper (BKR) #287 standing in front of the thermostat. BKR #287 revealed the thermostat was locked on a degree setting of 68 degrees F and had a current temperature of 66…

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

Based on observation, staff interview, and policy review, the facility failed to ensure mechanically altered diets were prepared to a proper consistency to ensure safe consumption. This had the potential to affect eleven Residents (#3, #9, #19, #30, #33, #34, #35, #37, #49, #327, #379) who were identified by the facility to have a minced and moist mechanically altered diet order. The facility census was 69. Findings include: Observation and interview during the mechanical altered food preparation on 01/16/24 at 11:46 A.M. revealed Dietary [NAME] (DC) #249 being informed to prepare the mechanical soft honey garlic chicken by Dietary Manager (DM) #814. DC #249 was observed grabbing five pieces of chicken and placing it on a white cutting board. DC #249 was observed using a handheld knife to hand chop up the chicken and place it in a serving dish for the steam table. Observation revealed the chicken pieces were chopped by hand and were approximately one inch by one inch in size. DC #249 revealed she was allowed to prepare all mechanically altered diets by hand, except the pureed diets.…

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 and interview, the facility failed to ensure a urinary catheter bag had a privacy cover over it to maintain privacy and dignity for Resident #49. This affected one Resident (#49) of two residents (#49 and #64) who had urinary catheters. The census was 69. Findings include: On 01/17/24 at 12:25 P.M. observation of Resident #49 in the facility dining room eating lunch revealed his urinary catheter bag collecting urine was not in a privacy cover. Interview on 01/17/24 at 12:26 P.M. with Assistant Director of Nursing (ADON) #811 verified Resident #49 was eating lunch in the dining room and the urinary catheter bag did not have a privacy covering over it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a baseline nursing care plan for Resident #75 according to the regulation requirement. This affected one Resident (#75) of 20 residents reviewed for care plans. The facility census was 69. Findings include: Record review revealed Resident #75 was admitted to the facility on [DATE] and discharged on 10/18/23 with diagnoses including malignant neoplasm of oropharynx, drug induced pancytopenia, anemia due to antineoplastic chemotherapy, elevated white blood cell count, localized swelling, mass and lump of the neck and head, malignant neoplasm of prostate cancer, chronic kidney disease stage three, peripheral vascular disease and acute respiratory failure. Review of the admission assessment dated [DATE] revealed Resident #75's functional assessment was one person assist. He was partial weight bearing. He was oriented to time, place and person. Further review of the medical record revealed no evidence a baseline care plan involving Resident #75's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident, family and staff interviews, and review of facility policy, the facility failed to ensure nail care was provided for Resident #23 and timely incontinence care was provided for Resident #35. This affected two residents (#23 and #35) of three residents reviewed for activities of daily livings (ADL). The facility census was 69. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 06/17/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, spinal stenosis, and dependence on wheelchair. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 that indicated Resident #23 was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #23 utilized a wheelchair and was dependent for ADLs. Review of the care plan dated 09/12/23 revealed Resident #23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure adequate supervision of Resident #46 to prevent a fall. This affected one resident (46) of two residents reviewed for falls. The facility census was 69. Finding include: Record review was conducted for Resident #46 who was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visual loss both eyes, visual hallucination, vascular dementia, hypertension, peripheral vascular disease, localized edema, and glaucoma. Review of the quarterly Minimum Data Set ( MDS) 3.0 assessment, dated 10/12/23, revealed the resident had clear speech and made self-understood, was cognitively intact, had no known displays of physical or verbal behavior symptoms, exhibited no rejection of care, and her functional range of motion for upper and lower extremities was impaired. Resident #46 required a wheelchair for mobility, maximal assistance for bathing and site…

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 and interview the facility failed to date insulin pens when opened. This affected four (Resident #4, #5, #36, and Resident #51) of five residents reviewed for medication storage. The facility census was 69. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had intact cognition. Review of physician orders revealed an order for lispro injection solution dated [DATE]. Review of the Medication Administration Record (MAR) revealed Resident #4 received lispro injection of four units on [DATE]. 2. Review of the medical record for Resident #5 revealed an admission date of [DATE]. Diagnoses included diabetes mellitus. Review of the comprehensive MDS 3.0 assessment, dated [DATE], revealed the resident had intact cognition. Review of physician orders revealed an order for Humalog solution dated…

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

Based on observation and interview, the facility failed to ensure staff removed gloves after emptying a catheter and before proceeding to touch Resident #49's personal items. This affected one resident (#49) of 20 residents reviewed for infection control. The census was 69. Findings include: Observation was conducted on 01/17/24 at 2:36 P.M. of State Tested Nursing Assistant (STNA) #237 emptying Resident $49's urinary catheter bag. STNA #237 emptied the urine from the catheter bag and did not remove her gloves after completing the task. STNA #237 came back out of Resident #49's bathroom with the same gloves on and adjusted his bedside table closer to him, straightened his personal belongings on top of the table and pushed his newly opened bottle of water closer to him to be in his reach. Interview on 01/17/24 at 2:38 P.M. with STNA #237 confirmed she completed emptying Resident #49's catheter bag and did not remove her gloves or wash her hands after the task and before handling Resident #49's personal items.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to ensure call lights and resident telephones were within reach. This affected four (Residents #25, #34, #45 and #54) of 10 residents observed for call light placement. The census was 65. Findings included: Review of the medical record for Resident #25 revealed an admission date of 08/23/23. Diagnoses included encephalopathy, unspecified, paraplegia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition and required extensive assistance for bed mobility. Review of the medical record for Resident #34 revealed an admission date of 07/24/23. Diagnoses included morbid obesity, altered mental status and Parkinson's disease. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #34 had impaired cognition and required extensive assistance for bed mobility. Review of the medical record for Resident #45 revealed an admission date of 08/11/23. Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview the facility failed to allow residents to have personal items in their rooms. This affected one (Resident #65) of three residents reviewed for access to personal items. The census was 65. Findings included: Review of the medical record for Resident #65 revealed an admission date of 03/30/22. Diagnoses included multiple sclerosis (MS), Alzheimer's disease, and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #65 had intact cognition. Review of plans of care care dated 01/17/23 revealed Resident #65 had behaviors of including calling emergency services and daughter several times a day. No behaviors were documented related to threatening staff, recording staff or other residents. Review of the nurse progress notes for the past three months revealed no entries regarding Resident #65 having unsafe behaviors. Interview on 08/31/23 at 7:49 A.M. with Resident #65 revealed she had MS and it was difficult to use…

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.