Heritage Healthcare of Lyndhurst

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide residents with the correct last covered day (LCD). This affected five (Resident #60, Resident #63, Resident #73, Resident #79, and Resident #80) of eleven residents reviewed for liability notices. The census was 81. Findings include: 1. Review of Resident #60's medical record revealed she was admitted to the facility on [DATE]. She was still a resident and had not been discharged . A NOMNC letter revealed skilled services ended on 02/15/25, the LCD. The medical record provided no evidence of Resident #60's next payor source starting on 02/16/25. 2. Review of Resident #63's medical record revealed she was admitted to the facility on [DATE]. She was still a resident and had not been discharged . A NOMNC letter revealed skilled services ended on 11/23/24, the LCD. The medical record provided no evidence of Resident #63's next payor source starting on 11/24/24. 3. Review of Resident #73's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #5 revealed an admission date of 01/29/25. Diagnoses included cerebrovascular disease, dementia, psychotic disturbance, mood disturbance and anxiety, and dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and was dependent on staff for personal hygiene and transfers. Observation on 03/24/25 at 11:05 A.M, revealed Resident #5 was lying in bed. The resident had a floor mat to the right side of the bed. The mat was covered with a dried white substance. The carpeted next to the mat had large areas with a dried white substance. Interview 03/24/25 at 11:10 A.M. with Housekeeper #242 verified the dirty floor mat and spillage on the carpet. Housekeeper #242 stated she did not get to clean Resident #5 room today. This deficiency represents non-compliance investigated under Complaint Number OH00163018. Based on record reviews, observations and interviews, the facility failed to ensure a clean and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure quarterly care plan meetings were offered/completed for Resident #13. This affected one resident (#13) of one resident reviewed for quarterly care plan timing. The facility census was 81. Findings include: Record review for Resident #13 revealed an admission date of 03/08/20. Diagnoses included cerebral infarction, neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, resistant to multiple antimicrobial drugs, constipation, and muscle weakness. Review of the modification of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had impairment on both sides of her lower extremities, required partial/moderate assistance with eating and was dependent on staff for toilet hygiene, bathing, bed mobility, and transfers, and required substantial/maximal assistance for personal hygiene. Resident #13 had an indwelling catheter and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #42 revealed an admission date of 03/06/25. Diagnoses included sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease. Review of the laboratory service report dated 03/06/25 at 10:11 A.M. revealed the urine culture resulted Escherichia coli and extended spectrum beta lactamase (ESBL) producing organism. The report revealed the organism was resistant to ciprofloxacin and sensitive to Macrobid. Review of the admitting medications reconciliation dated 03/06/25 revealed ciprofloxacin 250 milligram (mg) twice daily was crossed off not to be administered. Review of Resident #42's physician orders dated 03/06/25 at 6:13 P.M. revealed an order dated 03/08/25 for Macrobid 100 milligrams, an antibiotic, two times a day to treat urinary tract infection. Review of the nursing progress note dated 03/08/25 stated Macrobid oral capsule 100 mg by mouth two a day for Urinary tract infection (URI) was not available. Review of the starter kit replacement form…

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 apply Resident #179's Automatic Positive Airway Pressure (auto-PAP) machine as ordered. This affected one resident (#179) of four residents reviewed for respiratory care. The facility census was 81. Finding include: Review of Resident #179's medical record revealed an admission date of 06/14/22 with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD), obesity, and emphysema. Resident #179 was discharged on 02/21/25. Review of the physicians order for February 2025 revealed an order for an auto-PAP (a respiratory machine worn while sleeping which provides positive airway pressure and automatically adjusts in response to measured airway resistance) to be applied every night and as needed for naps. Review of the Treatment Record (TAR) for February 2025 revealed the treatment was signed off on for evening on 02/19/25 and 02/20/25. Review of the nursing assessment dated [DATE] revealed Resident #179 was alert and orientated…

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.

3. Review of the medical record for Resident #42 revealed an admission date of 03/06/25. Diagnoses included sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease. Review of the comprehensive Minimum Data Set 3.0 dated 03/12/25 revealed the resident had moderate cognitive impairment and was dependent on staff for toileting, transfers and ambulation. The assessment indicated the resident received and antibiotic and antiplatelet. Review of Resident #42's physician orders revealed an order dated 03/08/25 for Macrobid 100 milligrams (mg), an antibiotic, administered two times a day to treat urinary tract infection (UTI). Review of progress note dated 03/08/25 at 6:30 P.M. revealed a new order was placed for Macrobid 100 mg to be administered twice daily for a duration of ten days to treat a UTI. The note stated the order was outside of the recommended dose or frequency. The dose failed a general dose range check, and the drug's dose should be adjusted based on renal function. The note concluded by noting manual screening was required. Additional review of…

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

Based on record review and interview the facility failed to ensure accurate documentation in the medical record. This affected two residents (Resident #42 and #179) of two residents reviewed for accuracy of medical records. The facility census was 81. Findings include: 1. Review of Resident #179's medical record revealed an admission date of 06/14/22 with diagnoses including Respiratory failure, chronic obstructive pulmonary disease (COPD), obesity, and emphysema. Resident #179 was discharged on 02/21/25. Review of the physicians order for February 2025 revealed an order for an auto-pap (auto-adjusted positive airway pressure) to apply as needed for naps and every night. Review of the Treatment Record (TAR) for February 2025 revealed the treatment was signed off on for evening on 02/19/25 and 02/20/25. Review of Self-Reported Incident (SRI) 257446 dated 02/21/25 revealed the Nurse Practitioner (NP) reported that staff failed to follow treatment order for Resident #179 auto-pap. The witness statement for Licensed Practical Nurse (LPN) #351 taken by the Administrator per phone stated…

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

Based on observations, interviews, and review of the facility policy and procedures the facility failed to ensure proper storage of food items and failed to maintain a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect 76 of 81 residents in the facility as five residents (Resident #17, #35, #44, #52, and #62) received nothing by mouth. The facility census was 81. Findings include: 1. Observation during the initial tour of the kitchen on 03/24/25 from 9:50 A.M. to 10:30 A.M. revealed observation of the walk-in freezer #2 with several boxes of frozen food stored on the floor of the freezer. Dairy walk-in cooler #3 had an opened box of hard boiled eggs in clear plastic bags with one of the clear plastic bags opened and undated, and a clear container with cooked fish with the lid opened. The prep table with the Robocoup had several dried, beige, food splatters and what looked like shredded cheese pieces on table next to the Robocoup. A moderate amount of various food crumbs were observed on bottom shelf of the prep table on the large white…

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 4. Review of the medical record for Resident #9 revealed an admittance date of 03/13/23 with diagnoses including spinal injury at T7 through T10, paraplegia, spinal stenosis, hypertension, depression, and heart failure. Review of Resident #9's physician orders for March 2025 revealed morning medications that included Allopurinol 100 milligram (mg), 0.6 mg Colchicine 0.6 mg. Furosemide 40 mg, multivitamin, potassium 20 milliequivalents (meq), vitamin B12, Vyvanse 40 mg, Flomax 0.4. and Gabapentin 800 mg. Observation on 03/26/25 at 7:57 A.M. of medication administration with Registered Nurse (RN) #310 revealed the nurse prepared Resident #9's morning medications and administered the medications. There was no hand sanitizer on the medication cart. RN #310 did not sanitize or wash hands prior to preparing medication Resident #9 medications or after administering the medications. Interview on 03/26/25 at 8:40 A.M. with RN #310 verified she did not sanitize or wash her hand prior to administering medication 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 medical record review and staff interview the facility failed to ensure an environment free of accidents hazards when smoking materials were not secured to prevent Resident #1 from smoking in his room. This affected one (#1) of three residents reviewed with a diagnosis of dementia on the locked nursing unit and the 24 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25)additional residents residing on the locked memory care nursing unit. Facility census was 72. Findings include: Clinical record review revealed Resident #1 was admitted on [DATE] with diagnoses including dementia with behaviors, high blood pressure, chronic obstructive pulmonary disease, anxiety, disorder of kidney and ureter, chronic viral hepatitis, malnutrition and traumatic brain injury. A review of Resident #1's Minimum Data Set assessment dated [DATE] indicated Resident #1's cognition was intact. A review of Resident #1's hospital record dated 12/16/24 indicated he had 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, interview, medical record review, and policy review, the facility failed to ensure Resident #17, who had chronic pain syndrome and received routine and as needed medication to treat pain, was provided pain medication as requested to effectively manage her chronic pain. This affected one resident (#17) of three residents reviewed for pain management. The facility census was 66. Findings Include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Amyotrophic Lateral Sclerosis (ALS), fibromyalgia, chronic pain syndrome, major depression disorder, anxiety disorder, and insomnia. Review of the physician's orders for Resident #17 revealed on 02/27/24 the resident was admitted to hospice for the diagnosis of ALS. She was receiving Ambien (a hypnotic medication for sleep) 10 milligrams (mg) between 11:30 P.M. and 12:30 A.M., Ativan (anti-anxiety medication) 0.5 mg every four hours as needed, Gabapentin (a medication used to treat nerve…

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 provide feeding assist for Residents #5 and #6 and personal care assist with a mechanical lift for Resident #35 in a dignified and respectful manner. This affected three residents (#5, #6 and #35) of three residents reviewed for dignity and respect. The facility census was 68. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 04/26/16 with diagnoses including quadriplegia and anxiety disorder. Physician orders effective October 2024 indicated a regular diet, texture and consistency, and to give feeding assistance with all meals as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] specified Resident #5 had no cognitive impairment and was dependent on one staff physical assist for eating. Review of the medical record for Resident #6 revealed an admission date of 02/20/24 with diagnoses including amyotrophic lateral sclerosis, chronic pain syndrome,…

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 facilities self reported incidents (SRIs), medical record review, policy review, family interview, staff interview, and facilities policy review, the facility failed to ensure residents responsible parties and medical practioners were notified of an instance of potential sexual abuse. This affected two (Residents #100 and #101) of three residents reviewed for notification of change. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). Review of census records revealed Resident #100 was her own responsible party but relied on her mother to make all necessary medical and financial decisions.…

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 self-reported incidents (SRIs), medical record review, policy review, police report review, family interview and staff interview, the facility failed to ensure Resident #100 was free from sexual abuse. This affected one of three residents reviewed for abuse. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). Resident #100 was discharged to another skilled nursing facility on 07/29/24 Review of the care plan dated 07/19/21 revealed Resident #100 has noted behaviors such as attention seeking, making false accusations of staff and others and rejection of care. The medical record also noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review,staff interview, and facility policy review, the facility failed to ensure it implemented its abuse policy related to an incident of potential sexual abuse against Resident #100. This affected one (Resident #100) of three residents reviewed for abuse. This had the potential to affect all residents. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). Review of census records revealed Resident #100 was her own responsible party but relied on her mother to make all necessary medical and financial decisions. Resident #100 was discharged to another skilled nursing facility on 07/29/24.…

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 review of facility self-reported incidents (SRIs) ,medical record review and staff interview the facility failed to ensure a complete and accurate medical record for residents. This affected two (Residents #100 and #101) of three residents reviewed for accuracy of medical records. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). Review of census records revealed Resident #100 was her own responsible party but relied on her mother to make all necessary medical and financial decisions. Resident #100 was discharged to another skilled nursing facility on 07/29/24. Resident #101 was admitted to 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, interview and policy review, the facility failed to ensure a clean and sanitary kitchen environment including labeling and dating food, discarding expired food and appropriate monitoring of the low-temperature dish machine. This had the potential to affect 53 residents receiving food from the kitchen as four residents (Residents #2, #7, #47 and #54) received nothing-by-mouth (NPO). Facility census was 57. Findings include: 1. Observation of the kitchen on 04/15/24 from 8:32 A.M. to 9:13 A.M. with District Dietary Manager (DDM) #132 revealed the following areas of concern: • In the walk-in cooler, there were packs of sliced cheese and turkey that lacked labels and dates. There was a loosely wrapped package of hard-boiled eggs that were not labeled or dated. There was an additional package of white cheese slices not dated and sausage that had an illegible date. There was a cut of pork wrapped in foil with writing on the foil indicating it was fully cooked but no date was on the foil. There was a package of corned beef that was opened and not dated. • In 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, interview and facility policy review, the facility failed to ensure trash including biohazardous waste was collected and stored appropriately. This had the potential to affect all 57 residents residing in the facility. Findings include: 1. Observation on 04/15/24 starting at 9:13 A.M. with District Dietary Manager (DDM) #132 revealed multiple dumpsters were placed in the parking lot area behind the facility. DDM #132 took the surveyor to the designated dietary dumpster which was open and had a pile of debris next to the dumpster including cut up onions, leaves and Christmas lights. There was a broken dresser, chair and couch near the dumpster. Observation continued to the right most point of the parking lot where snow plow markers, a box, trash and takeout were all outside of the dumpster. A wooden open gated area near this dumpster contained a red biohazard barrel and a bookshelf. Interview with DDM #132 at the time of observation verified the dumpster area was not reasonably clean and that the biohazardous waste should not have been in the parking lot. 2. A…

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

Based on observation, interview, record review and facility document review, the facility failed to ensure washing machines hit minimum required temperatures for hot water processing. These findings had the potential to affect all 57 residents within the facility. Findings include: Observation on 04/16/24 starting at 8:13 A.M. revealed the soiled linen laundry room contained three washers. The washers did not have a temperature gauge on them. No temperature logs were observed. On the wall there was a listing of different laundry cycles but this lacked temperature information. Laundry Aide (LA) #139 donned a gown and gloves then started to load linens into the washing machine, breaking open clear bags and putting the items in the drum of the washing machine. When the surveyor inquired about temperatures during the wash cycle, LA #139 placed a yellow plate thermometer into the wash and started the cycle. Interview on 04/16/24 at 7:45 A.M. with Housekeeping and Laundry Supervisor (HLS) #138 revealed the washing machine got to a temperature of 140 degrees Fahrenheit (F). HLS #138 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the menu and spreadsheet, the facility failed to ensure foods were served in appropriate quantities. This affected 49 residents receiving food from the kitchen as four residents (#2, #7, #47, #54) were ordered nothing-by-mouth (NPO) and four additional residents (#12, #31, #43 and #56) were scheduled to receive a different entree at the meal as they were on a regular No Added Salt (NAS) diet. Facility census was 57. Findings include: Review of a menu for Week 1, Tuesday for lunch revealed a meal consisting of baked macaroni and cheese, tomatoes [NAME], rosemary dinner roll and fruit cocktail. An alternate was listed as marinated chicken thigh, green beans and mashed potatoes. Review of the diet guide sheet for Tuesday (Day 3) Lunch corresponding to 04/16/24 revealed for the entrée of macaroni and cheese, residents were to receive one cup (eight ounces) of baked macaroni and cheese on a regular, dysphagia advanced (mechanical), dysphagia mechanical and carbohydrate…

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 an allegation of misappropriation of property was reported to the State agency. This affected one (Resident #6) of five residents reviewed for abuse and misappropriation. The facility census was 57. Findings include: Interview with Long Term Care Ombudsman #133 on 04/15/24 at 1:22 P.M. revealed she received a concern that Resident #6's lockbox containing roughly $35.00, a checkbook, and a bank card went missing from her room. The items were noted missing 03/31/24 and it was reported to a facility nurse on 04/01/24. The ombudsman sent an email regarding the issue to the Administrator on 04/06/24 and discussed it with her on 04/12/24. Interview with Resident #6 on 04/17/24 at 8:32 A.M. revealed her lock box containing between twenty and fifty dollars, a check book, and a bank card was taken out of her room. She was unsure how long it was missing. She reported it to management and no one addressed the situation. Record review of the Ohio…

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

Based on review of personnel files, review of facility policy and interviews with staff, the facility did not ensure all employees were checked against the nurse aide registry (NAR) and had evidence of Bureau of Criminal Investigation (BCI) checks. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Findings Include: Review of employee personnel files revealed the following: Review of the personnel file for Dietary Manager (DM) #601, hire date of 01/02/24, revealed no evidence of a check against the nurse aide registry (NAR). Review of the online Ohio NAR for DM #601 revealed no findings for DM #601. Review of the personnel file for Employee #834, hired in December 2023 into the position of nurse, revealed no evidence of a criminal background check. Review of the facility Bureau of Criminal Investigation and Identification Log dated 02/02/24 through 02/29/24 revealed Employee #834 was not listed on the log. Interview on 03/04/24 at 2:15 P.M. with the Regional Director of Operations (RDO) #600 revealed the current company took over…

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, review of the activity calendars and facility policy, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the needs and preferences of the residents. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Findings include: Observation on 02/27/24 at 9:39 A.M. of the first floor activities bulletin board revealed an empty display with no activity calendar posted. A confidential interview on 02/27/24 at 9:39 A.M. with Employee #813 revealed activities were offered, but there were no activities in the evenings or on the weekends. Interview on 02/27/24 at 9:49 A.M. with Resident #55 revealed the facility only offered bingo and painting. Resident #55 revealed there were no other activities offered. Interview on 02/27/24 at 10:01 A.M. with Resident #15 revealed she did not go to activities because all that facility offered was bingo and she did not like bingo. A confidential interview on 02/27/24 at 10:13 A.M. 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 personnel record review, staff interview and review of the facility activity director job description, the facility failed to ensure a qualified professional was in place to act as the activity director and direct the facility's activity program. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Findings include: Review of the personnel file for Activity Director (AD) #603 revealed a date of hire of 09/15/22 with no date of separation listed. Interview on 02/27/24 at 11:54 A.M. with the Director of Nursing (DON) revealed the facility no longer had an activity director in place. The DON revealed AD #603 recently put in her notice of separation and subsequently went on medical leave shortly after. The DON revealed there was one activity employee who worked whenever they needed her to, including on her off days. The DON revealed the activity employee worked five days a week, full time. Follow-up interview on 02/27/24 at 3:25 P.M. with the DON revealed AD #603's last day worked was approximately in December of 2023. A…

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

Based on observation of a test meal tray, resident interviews, staff interviews and facility policy review, the facility failed to serve hot, palatable, and visibly pleasing foods. This had the potential to affect all residents, except Residents #2, #8, #11, #49, and #60, who were identified by the facility a consuming nothing by mouth (NPO). The facility census was 61. Findings include: Interview on 02/27/24 at 9:49 A.M. with Resident #55 revealed the facility's food was nasty with no alternatives, and the chicken patties were nasty. Interview on 02/27/24 at 10:01 A.M. with Resident #15 revealed the facility's food was nasty, can't eat it or stomach it. My brother orders food for me and has it delivered. The kitchen doesn't follow my preferences Interview on 02/27/24 at 10:24 A.M. with Resident #16 revealed the facility's food was nasty and she was not provided a menu to order alternatives. Interview on 02/27/24 at 11:05 A.M. with Resident #44 revealed the facility's food was served cold. A confidential interview on 02/27/24 at 11:15 A.M. with Employee #834 revealed residents…

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 personnel record review, review of the job description for social services director and staff interview the facility failed to employ a full-time Licensed Social Worker (LSW). This had the potential to affect all residents residing in the facility. The facility census was 61. Findings include: Review of the personnel file for LSW #602 revealed a date of hire of 09/19/22 with no date of separation listed. Review of an email correspondence on 03/05/24 at 3:52 P.M. with the Director of Nursing (DON), Administrator, and Regional Director of Operations (RDO) #600 revealed LSW #602's date of separation was 02/15/24. Interview on 02/27/24 at 11:54 A.M. with the DON revealed the facility no longer had an LSW in place. The DON revealed LSW #602 was no longer employed at the facility and no other LSW was hired in her place. Interview on 02/28/24 at 3:16 P.M. with Human Resources Director (HRD) #701 revealed her date of hire was 02/05/24 and at that time the facility employed an LSW. HRD #701 revealed she was unsure of LSW #602 exact date of separation. Review of the facility document…

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

Based on observation, staff interviews, and review of a police report, the facility failed to ensure all door locks in the facility kitchen properly worked to maintain a safe and secure environment at all times. This affected all 61 residents residing in the facility. The facility census was 61. Findings include: Review of a document titled City of Lyndhurst Police Department (CLPD) Call Summary Report, printed on 02/27/24, revealed on 01/26/24 at 6:57 P.M. the CLPD received a call regarding a suspicious person. Review of the report revealed several supervisors, who were not at the scene, had made calls and reported a suspicious person was running around with a mask and had exited the building prior to the officer's arrival. The officer checked the interior of the facility and left without further incident. Confidential interviews on 02/27/24 from 10:53 A.M. to 12:12 P.M. with Employee #810, #822, #834 and #915 revealed a door in the facility kitchen did not securely lock. Employee #915 revealed the facility was searched by police recently due to an incident involving an unknown,…

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 facility policy review, the facility failed to maintain a safe, clean, comfortable and sanitary environment in resident rooms affecting 17 Residents (#16, #39, #55, #25, #44, #51, #21, #3, #4, #6, #8, #9, #49, #58, #17, #57 and #56), and failed to maintain the second floor shower room in a safe, clean and sanitary manner which had the potential to affect an additional 21 residents living on the second floor (#1, #2, #5, #7, #10, #11, #13, #14, #18, #19, #22, #23, #24, #27, #28, #29, #30, #33, #38, #40, and #48.). The facility census was 61. Findings include: Interview and observation on 02/27/24 at 10:24 A.M. with Resident #16 revealed she felt her room was dirty and it needed to be painted. Resident #16 revealed she was embarrassed to have visitors due to the uncleanliness of her room. Observation revealed the door to her bathroom had various spots with missing paint, the floors appeared dirty and not mopped, and all four walls of her room had multiple scruffs, smears, and unidentified drip spots. Observation 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, staff interview, and record review, the facility failed to ensure urinary catheter drainage bags were covered for privacy and did not eminate a strong odor of urine that could be smelled in the room and into the hallway and therefore traced to Resident #2's room. This affected one resident (#2) of one resident reviewed for urinary catheters. Findings include: Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including pneumonia, functional quadriplegia, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #2 had a Brief Mental Status (BIMS) score of 9 indicating cognitive impairment, and Resident #2 was dependent on staff for activities of daily living (ADLs), was incontinent of urine and bowel, and had an indwelling catheter in place. Review of the physician orders dated 02/07/24 revealed Resident #2 had orders in place for foley catheter care every shift, foley catheter bag cover…

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 policy and staff interview, the facility failed to ensure Resident #17's care plan was revised to reflect accurate advanced directives ordered by the physician as decided by the resident representatives. This affected one resident (#17) of three residents reviewed for accurate care plans. The facility census was 61. Findings include: Review of the medical record for Resident #17 revealed an admission date of [DATE] with diagnoses including dementia, atherosclerotic heart disease, and gout. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had cognition impairment. Review of the physician order dated [DATE] revealed an order to have a hospice consultation. Review of the physician order dated [DATE] revealed an order for Do-Not-Resuscitate Comfort Care (DNRCC). Review of the Do-Not-Resuscitate (DNR) order form dated [DATE] revealed Resident #17 had a DNRCC order in place to be effective immediately. Review of the progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility did not ensure Resident #14 was appropriately supervised by two staff while being transferred using a mechanical lift. This affected one resident (#14) of three residents reviewed for hazard risks. The facility census was 61. Findings include: Review of the medical record for Resident #14 revealed an admission date of 10/21/22 with diagnoses including paraplegia, bipolar disorder, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 11/09/23 revealed Resident #14 had a self-care performance deficit related to paraplegia and was at risk for falls with interventions including assist with transfers as needed and assist of two for transferring via hoyer lift (mechanical lift). Interview on 03/04/24 at 5:25 A.M. with Employee #703 revealed there was one nurse and two aides 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 resident record review, family interview, staff interviews, and review of the facility hospice contract, the facility failed to ensure hospice services were implemented in a timely manner. This affected one resident (#43) of three residents reviewed for hospice services. The facility census was 61. Findings include: Review of the medical record for Resident #43 revealed an admission date of 02/02/24 with diagnoses including sepsis, urinary tract infection, severe protein-calorie malnutrition, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, and Resident #43 required assistance from staff for activities of daily living (ADLs). Review of the progress note dated 02/07/24 at 1:51 P.M. revealed Resident #43 had a care conference that included the interdisciplinary team and family. Review of the progress note revealed Resident #43…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure the urinary cathetar drainage bag for Resident #2 was not sitting uncovered and directly on the floor exposing the bag to a source of contamination and potential infection. This affected one resident (#2) of one resident reviewed for urinary catheters. The facility census was 61. Findings include: Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses that included pneumonia, functional quadriplegia, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #2 had a Brief Mental Status (BIMS) score of 9 indicating cognitive impairment, and Resident #2 was dependent on staff for activities of daily living (ADLs), was incontinent of urine and bowel, and had an indwelling catheter in place. Review of the physician orders dated 02/07/24 revealed Resident #2 had orders in place for foley catheter care every shift, foley catheter bag…

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 accurate advance directives for Resident #35. This affected one resident (#35) of two residents reviewed for advanced directives. The facility census was 60. Findings include: Review of Resident #35's medical record revealed an initial admission date of [DATE] from an acute. Diagnoses included acute congestive heart failure, type 2 diabetes mellitus, atrial fibrillation, osteoarthritis, hypertension, chronic kidney disease, hyperlipidemia, ulcerative colitis, dementia, depression, and anxiety. Review of the Resident #35's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was able to verbalize her needs, understood others, made herself understood and had no apparent cognitive deficit. The assessment indicated a BIMS (Brief Interview of Mental Status) score of 15 out of 15. Review of the plan of care initiated on [DATE] revealed Resident #35 and her family had chosen a DNR (Do Not Resuscitate) status, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the hospital with information on Resident #115's background and current condition. This affected one resident (#115) of three residents reviewed for hospitalization. The facility census was 60. Findings include: Review of the medical record for Resident #115 revealed an admission date of 05/10/23 and a discharge date of 07/18/23. Diagnoses included hypertension, depression, schizophrenia, and seizures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 was not assessed for cognition. She required dependence of one person for toilet use, limited assistance of one person for dressing, and supervision of one person for bed mobility and hygiene. Review of the progress note dated 6/25/23 revealed Resident #115 had a seizure. The nurse practitioner was notified and ordered a transfer to the local emergency department (ED). 911 was called, and the resident was transferred by ambulance to the ED. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #115's care plan was updated to include accurate information. This affected one resident (#115) of three residents reviewed for care plans. The facility census was 60. Findings include: Review of the medical record for Resident #115 revealed an admission date of 05/10/23 and a discharge date of 07/18/23. Diagnoses included hypertension, depression, schizophrenia, and seizures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 was not assessed for cognition. She required dependence of one person for toilet use, limited assistance of one person for dressing, and supervision of one person for bed mobility and hygiene. Review of the care plan dated 05/11/23 revealed no evidence the Residents' seizure disorder was included in the care plan. Interview on 11/22/23 at 12:45 P.M. with the Director of Nursing (DON) confirmed Resident #115's seizure disorder was not addressed in the care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #15's oxygen was administered as ordered. This affected one (#15) of three residents reviewed for physician's orders. The facility census was 60. Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/16/23. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, obesity, asthma, chronic respiratory failure with hypoxia, and anxiety. Review of the physician's orders for November 2023 revealed Resident #15 was to receive oxygen at two liters per minute continuously. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. She was totally dependent on staff for showers, required supervision of one person for bed mobility and eating, and supervision with touch assistance for oral hygiene and toileting. She received oxygen. Review of the care plan dated 09/08/23 revealed Resident #15…

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

Based on record review and interview, the facility failed to ensure behaviors were monitored in conjunction with the use of psychotropic medications. This affected one resident (#49) of five residents reviewed for unnecessary medications. The facility census was 60. Findings include: Review of the medical record for Resident #49 revealed an admission date of 10/14/23. Diagnoses included Alzheimer's disease, anxiety, dementia, insomnia, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment completed 10/21/23 revealed Resident #49 was cognitively intact. He was independent with oral care, toileting, and hygiene. Review of the physician's orders for November 2023 revealed an order for Seroquel (antipsychotic) 100 milligrams (mg) at bedtime for behaviors. Review of the Medication Administration Record (MAR) for November 2023 revealed no evidence behaviors were being tracked for the use of Seroquel. Interview on 11/21/23 at 3:50 P.M. with the Director of Nursing (DON) confirmed behaviors were not being tracked for the use of Seroquel for Resident #49.

Based on observation and interview, the facility failed to maintain a homelike physical environment. This had the potential to affect all residents residing in the facility. The facility census was 62. Findings include: Observation on 10/11/23 at 2:38 P.M. revealed a sign on second floor shower room door to clean daily and deep clean on Mondays, Wednesdays, and Fridays. Interview on 10/11/23 at 5:21 P.M. with State Tested Nursing Assistant (STNA) #804 revealed the shower room on second floor was usually cleaned by STNAs on second shift. STNA #804 indicated they would get cleaning supplies from housekeeping. Interview on 10/12/23 at 6:35 A.M. with Housekeeping Director #810 revealed housekeeping staff cleaned shower rooms daily. Housekeeping Director #810 indicated they had one resident complaining of mold in shower rooms. Housekeeping Director #810 indicated their department does not address mold and the maintenance department would be responsible for mold. Housekeeping Director #810 indicated she posted the signs to let residents know the shower rooms were cleaned daily. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one resident (#3) of one resident reviewed for an indwelling urinary catheter. The facility census was 61. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, kidney failure, end stage renal disease, reduced mobility, depression, anxiety, heart disease, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/31/23, revealed Resident #3 was cognitively intact. The resident required extensive assistance of one staff for bed mobility, and extensive assistance of two staff for transfers and personal hygiene. The resident had an indwelling catheter for urine, utilized oxygen, and received dialysis services. Review of current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of the policy, the facility failed to ensure infection control was maintained for oxygen tubing, by storing nasal cannula's and tubing to prevent contamination and changing oxygen tubing as needed. In addition, the facility failed to ensure a physician's order was in place prior to administering oxygen. This affected one (#3) of one resident reviewed for oxygen. The facility census was 61. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, kidney failure, end stage renal disease, reduced mobility, depression, anxiety, heart disease, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/31/23, revealed Resident #3 was cognitively intact. The resident required extensive assistance of one staff for bed mobility, and extensive assistance of two staff for transfers and personal hygiene. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure sufficient staff to meet the needs of all residents during dining. This finding affected nine residents (Residents #12, #13, #59, #62, #73, #112, #114, #130 and #146) and had the potential to affect all 140 residents currently residing in the facility. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including quadriplegia, peripheral vascular disease, gastroesophageal reflux disease and vitamin deficiency. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview mental status (BIMS) score of 15 indicating the resident was cognitively intact. According to this assessment, Resident #13 was totally dependent with the assistance of one staff person for eating. Review of the nutrition assessment dated [DATE] revealed resident was on a regular diet. The resident had no significant weight change. Interview on 02/25/20 2:35 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, test tray, and interview the facility failed to serve food at appropriate and palatable temperatures and taste for Resident #13, #58, #73 and Resident #130. This affected four residents and had the potential to affect all 140 residents residing in the facility receiving meals/food from the kitchen. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including quadriplegia, peripheral vascular disease, gastroesophageal reflux disease and vitamin deficiency. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview mental status (BIMS) score of 15 indicating the resident was cognitively intact. According to this assessment, Resident #13 was totally dependent with the assistance of one staff person for eating. Review of the nutrition assessment dated [DATE] revealed resident was on a regular diet. The resident had no significant weight change. Interview on 02/25/20 2:35 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure Resident #62 was treated with dignity/respect after her morning meal. This affected one of two residents reviewed for dignity and respect. Findings include: Resident #62 was admitted to this facility on 05/03/17. Her admitting diagnoses included dementia with behavioral disturbance, hypertension, adult failure to thrive and restlessness and agitation. The Minimum Data Set assessment dated [DATE] revealed Resident #62 had severe cognitive impairment and she needed extensive assistance of two staff for bed mobility and toileting. She needed extensive assistance of one staff for dressing, transfers, and personal hygiene. For eating she needed limited assistance of one staff person to provide guided maneuvering of hands/arms. On 02/27/20 at 9:30 A.M., Resident #62's meal tray had been removed. There was spilled oatmeal laying on the table in front of her. The resident laid her hands on the table in the oatmeal and dozed off to sleep. At…

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 and record review, the facility failed to ensure Resident #34 received timely and appropriate notice of non-coverage when skilled Medicare services ended. This affected one of three residents reviewed for beneficiary protection notification. Findings include: Review of Resident #34's Notice to Medicare Provider Non-coverage (NOMNC) form revealed he was discharged from Medicare skilled nursing coverage on 12/13/19. The resident signed that he received and understood the notice on 12/13/19. Resident #34 remained as a resident in the facility following the discharge from Medicare covered services. There was no evidence found to verify Resident #34 was issued a CMS-10055 form informing them of their financial liability for remaining in the facility after Medicare covered services ended. Interview with Licensed Social Worker #823 on 02/25/20 at 4:04 P.M. confirmed the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate for Resident #45, Resident #73 and Resident #140. This affected three of 35 residents reviewed for accurate assessments. Findings include: 1. Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular/rapid heartbeat), altered mental status and dementia with behavioral disturbance. Review of Resident #45's physician orders revealed an order dated 12/06/19 for Humalog (fast acting) insulin, inject six units subcutaneously, three times a day with meals for diabetes and an order dated 09/17/19 for Lantus (long acting) insulin, inject 25 units subcutaneously, every night shift for diabetes. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was received six doses of insulin in the review period. Review of Resident #45's medication administration records (MARS) from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely assistance for Resident #13 and Resident #130, who were dependent on staff to eat meals. This affected two of two residents reviewed for Activities of Daily Living (ADL) assistance. The facility census was 141. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including quadriplegia, peripheral vascular disease, gastroesophageal reflux disease and vitamin deficiency. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview mental status (BIMS) score of 15 indicating the resident was cognitively intact. According to this assessment, Resident #13 was totally dependent with the assistance of one staff person for eating. Review of the nutrition assessment dated [DATE] revealed resident was on a regular diet. The resident had no significant weight change. Interview on 02/25/20 2:35 P.M. Resident #13 confirmed the food is…

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 assess and monitor Resident #73's head laceration (cut). This finding affected one (Resident #73) of three residents reviewed for accidents. Findings include: Review of Resident #73's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder and repeated falls. Review of Resident #73's Fall Occurrence Evaluation dated 02/13/20 indicated the nurse was made aware the resident had a fall and hit his head. Upon assessment, the resident was noted with an open area to the back of his head with bloody red drainage. The resident was alert and in stable condition. Pressure was applied to the cut on Resident #73's head and he was transported to the hospital. He returned to the facility with staples used to close his head laceration. During interview on 02/24/20 at 9:33 A.M. with Resident #73's mother, she pointed out he had staples in the back of his head. She said the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #31's pressure wound care was completed as ordered by the physician. This finding affected one of four residents reviewed for pressure ulcers. Findings include: Review of Resident #31's medical record revealed the resident was admitted on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal (kidney) disease with dialysis, hypotension (low blood pressure) and muscle weakness. Review of Resident #31's physician order dated 01/15/20 directed nursing staff to cleanse the right heel pressure ulcer with normal saline, pat dry, apply Santyl ointment (ointment with debriding properties), apply an adaptic dressing and cover with an abdominal dressing and Kerlix wrap daily and as needed. There was also a physician order dated 02/05/20 for nursing staff to cleanse the coccyx pressure ulcer wound with normal saline, pat dry, apply silver alginate (absorbent dressing to promote healing) and cover with a foam dressing daily and…

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