Cardinal Woods Skilled Nursing & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the resident council meeting minutes and staff interview the facility failed to ensure resident concerns were resolved in an appropriate manner and time frame. This affected five residents (Resident's #7, #27, #37, #66, #73) who resided on the Elmwood unit, 2 Resident's (#40 and #72) who resided on the Magnolia unit and had the potential to affect all residents residing in the facility. The facility census was 88. Findings include: 1. Review of the resident council minutes for the 08/30/21 meeting revealed a concern was brought to the attention of the facility regarding nurses being rude to residents and being preoccupied. Review of the resident council follow-up form revealed the action plan revealed no plan in place for the concern. Review of the follow-up form revealed a signature and date provided by the Director of Nursing (DON) on 02/23/22. Review of the resident council minutes for the 09/30/21 meeting revealed a concern was brought to the attention of the facility regarding nurses…

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

Based on record review, interview, and facility policy and procedure review, the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State Nurse Aide Registry (NAR) concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property as required. This had the potential to affect all 88 residents residing in the facility. Findings include: 1. Review of the personnel file for Licensed Practical Nurse (LPN) #873 revealed a hire date of 12/29/20. The printed evidence of LPN #866 being checked against the NAR was not completed until 01/07/21. Review of the personnel file for State Tested Nursing Assistant (STNA) #868 revealed a hire date of 03/30/21. The printed evidence of STNA #868 being checked against the NAR was not completed until the date the personnel file was requested for review during the survey on 06/08/22. Review of the personnel file for LPN #866 revealed a hire date of 04/26/21. 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 menu spreadsheet review, the facility failed to follow the menu as written. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88. Findings include: Review of the spreadsheet for Week One Tuesday, corresponding to 06/07/22 revealed portions of the meal were to be served were as follows: baked ham, three ounces; buttered noodles, four ounces; buttered cabbage, four ounces; applesauce, four ounces; bread; one slice. Residents on a mechanical soft diet were to receive a #6-scoop of ground ham. Residents on a pureed diet were to receive a #6-scoop of pureed ham, a #8-scoop of pureed buttered noodles, a #8-scoop of pureed cabbage and a #16-scoop of pureed bread. Observation of lunch tray service on 06/07/22 starting at 11:48 A.M. revealed the temperatures of the foods to be served were taken with the facility's self-calibrating thermometer by [NAME] #814 and portion sizes were established as follows: cabbage, 197 degrees F, four ounces; buttered…

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 menu spreadsheet review, the facility failed to serve palatable meals at appetizing temperatures. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88. Findings include: Review of the spreadsheet for Week One Tuesday, corresponding to 06/07/22 revealed portions of the meal were to be served were as follows: baked ham, three ounces; buttered noodles, four ounces; buttered cabbage, four ounces; applesauce, four ounces; bread; one slice. Observation of lunch tray service on 06/07/22 starting at 11:48 A.M. revealed the temperatures of the foods to be served were taken with the facility's self-calibrating digital thermometer by [NAME] #814 and were as follows: ham, 197 degrees Fahrenheit (F), 1 slice; cabbage, 197 degrees F, four ounces; buttered noodles, 169 degrees F, three ounces; pureed noodles, 146 degrees F, #12-scoop; pureed cabbage, 149 degrees F, #12-scoop; ground ham, 173 degrees F, #10-scoop. The portion sizes observed were verified by…

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 policy review, the facility failed to ensure a clean and sanitary kitchen. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88. Findings include: Observation of the kitchen on 06/06/22 from 8:59 A.M. to 9:21 A.M. with Regional Dietary Manager (RDM) #906 revealed the following concerns: • There was black material on the inner lip of the ice machine. • Floors were dirty and greasy throughout the kitchen with a higher build-up of grime by the oven and food preparation area. • The hoods had a greasy build-up. • The slicer was under a plastic bag. When the bag was lifted, the slicer was noted to be dirty with meat pieces still on it. • In the cooler, a rack with trays of fruit bowls was present. The plastic lids on the bowls were too small so they sat directly inside the bowls on top of the food that was ready to eat. Interview with RDM #906 verified the above areas of concern at the time of observation. RDM #906…

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 record reviews, the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 88 residents residing in the facility. Findings include: The following concerns were identified throughout the duration of the annual survey: 1. Record review was conducted of employee personnel files which revealed seven employees (Certified Nurse Aides (CNA's) #888 and #901, Licensed Practical Nurses (LPN's) #866 and #873, Registered Nurse (RN) #902, State Tested Nurse Aide (STNA) #868, and the Administrator) of eleven employee files sampled were not screened/checked through the Ohio Nurse Aide Registry (NAR) for abuse, neglect, exploitation, and misappropriation. Interview on 06/09/22 at 7:48 A.M. with Human Resources Director #908 confirmed screening/checking employees through the Ohio Nurse Aide Registry for abuse, neglect, exploitation, and misappropriation was not completed for CNA's #888 and #901, LPN's #866 and #873, RN…

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 implement appropriate infection control practices during a global pandemic. This had the potential to affect all residents residing in the facility. The facility census was 88. Findings Include: 1. Observation on 06/07/22 Certified Nurse Aide (CNA) #830 was observed sitting at the nurses' station with her N95 mask below her mouth. Interview with CNA #830 said she had just lowered her mask so she could breathe. She confirmed she should be wearing her N95 mask at all times while in the patient care areas. 2. Interview with the Administrator on 06/08/22 at 3:15 P.M. revealed Resident #73 had tested positive for COVID-19. The Administrator said she was asymptomatic and does not have a roommate. The facility is putting up a zip barrier in the doorway to her room for quarantine purposes and an isolation supply cart is being placed outside of her room. Her room had a sink and its own bathroom so they would not have to move her. The receptionist was currently sending out the robocalls notifying the family/responsible…

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

Based on staff interview, record review, and facility policy review the facility failed to ensure antibiotic usage was tracked for effectiveness. This had the potential to affect all residents residing in the facility. The facility census was 88. Findings Include: Review of the facility's antibiotic stewardship logs from April through June 2022 revealed they tracked the onset date of the infection, the type of infection, the antibiotic the resident was placed on, and if they were placed in isolation. No information was recorded regarding the dosage and duration of the antibiotics or if the antibiotic was to be administered orally, topically, or intravenously. No information was documented regarding if any lab work was obtained or what infection assessment tool or management algorithm was being used for tracking. Interview with the Director of Nursing (DON), who was also the facility's Infection Preventionist, on 06/13/22 at 10:15 A.M. revealed she received her Infection Preventionist certificate on 09/12/21. When asked what system the facility was using to track antibiotic usage…

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 and staff interview the facility failed to maintain a clean, functional, and well-maintained environment. This affected 22 residents (Resident's #3, #9, #10, #12, #13, #15, #18, #19, #23, #26, #35, #36, #39, #56, #72, #75, #76, #86, #88, #89, #290, and #388) and had the potential to affect all residents residing in the facility. The facility census was 88. Findings include: 1. Observation on 06/06/22 at 11:45 A.M. of Resident #290's bathroom revealed dried feces all over the toilet bowl. Licensed Practical Nurse (LPN) #896 verified the dried fecal matter at the time of discovery. 2. Observation on 06/06/22 at 10:39 A.M. of the carpet located on the Magnolia Unit in the common area, adjacent to the central nursing station, revealed multiple large stains. Housekeeping Supervisor (HSKS) #818 verified the findings at the time of discovery. 3. Observation on 06/06/22 at 11:15 A.M. of Resident #35's room, revealed a large spot of small white granules, identified as thickener, located near the end of her bed. The Director of Nursing (DON) verified the findings at 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 interview and record review the facility failed to ensure the physician was notified of physician orders not being followed and significant weight loss occurring for seven residents (Residents #24, #29, #31, #49, #53, #56, and #67) of nine residents on weekly weights. The facility census was 88. Findings Include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, tremors, psychosis, paranoid personality disorder, and hallucinations. Review of the physician's orders revealed on 06/08/22 the dietician added the nutritional supplement of Ensure Plus to be administered two times a day. On 06/15/22 weekly weights were ordered for Resident #24 Review of the weights for Resident #24 revealed an admission weight obtained on 03/10/22 of 205.8 pounds. His weight on 06/04/22 was 185 pounds indicating a severe weight loss of 10.11% over three months. Weights were obtained on 03/17/22, 04/02/22, 04/03/22, 05/01/22, 05/02/22, 05/05/22, 06/03/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure systems were in place for monitoring weights, implementing nutritional interventions to prevent avoidable weight loss, monitoring the percentage of supplements consumed, assessing weight loss, assessing residents for use of adaptive equipment, assisting residents with eating, notifying the physician of severe avoidable weight loss, and providing palatable food for the residents. This resulted in severe avoidable weight loss affecting five residents (Resident's #24, #29, #49, #53, and #56) of eight residents reviewed for nutrition. Two residents (Resident's #24 and #29) experienced severe avoidable weight loss over a three-month period of time and three residents (Resident's #49, #53, and #56) experienced a severe avoidable weight loss over a six-month period of time. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to…

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

Based on observation and interview, the facility failed to ensure pureed foods were prepared to the appropriate consistency. This affected eight residents (Resident's #6, #8, #12, #18, #29, #53, #60, #68 and #73) receiving a pureed diet. The facility census was 88 residents. Findings include: Observation on 06/07/22 starting at 11:12 A.M. of purees with Regional Dietary Manager (RDM) #906 and [NAME] #814 revealed no recipe was available during the observation. [NAME] #814 stated the recipe book was in there, referring to the kitchen office. At 11:35 A.M. [NAME] #814 placed a sixth pan full of ham slices into the food processor with an unmeasured amount of pork gravy. The ham slices were noted to still have the skin on them. After blending [NAME] #814 placed the mixture into the sixth pan indicating the puree was completed and ready for service. Upon taste of the mixture there were bits of the ham skin palpable on the tongue and bits of ham skin were also observed in the mixture sampled. RDM #906 then directed [NAME] #814 to re-blend the mixture. During the observed conversation 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 observation, staff interview, and medical record review, the facility failed to ensure dignity was respected regarding Foley catheter use. This affected one (Resident #81) of four residents (Residents #67, #29, #77, #81) reviewed for Foley catheters. The facility census was 88. Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including diabetes, stroke, heart disease, dementia without behavioral disturbance, anxiety, neuromuscular dysfunction of the bladder (a condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), and urinary retention. Resident #81 required use of a Foley catheter (a tube inserted into the resident's bladder to drain urine) due to neuromuscular dysfunction of the bladder and urinary retention. Observation on 06/09/22 at 9:47 A.M. revealed Resident #81 was in a wheelchair in the hallway being taken to therapy. The resident's Foley catheter drainage bag did not have a privacy…

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 ensure an Advanced Beneficiary Notice (ABN) was issued as required for Resident #89. This affected one (Resident #89) of three (Resident's #85, #89 and #900) reviewed for beneficiary notices. The facility census was 88. Findings include: Review of Resident #89's Notice of Medicare Non-Coverage (NOMNC) form for skilled services ending 01/06/22 and signed 01/04/22 revealed there was no ABN provided at the time of the NOMNC. Review of the medical record for Resident #89 revealed and admission date of 08/23/21. Medicare Part A services ended on 01/06/22, and Resident #89 continued to live in the facility until discharge on [DATE]. Interview on 06/08/22 at 2:10 P.M. with Social Service Designee (SSD) #904 verified Resident #89 received a NOMNC but was not provided an ABN as required. SSD #904 stated she was untrained in Medicare or skilled care services related to notification of benefits and in her role as a social service designee.

Based on interview, record review, facility policy review, and review of facility Self-Reported Incident (SRI) #222577, the facility failed to timely report to the State Agency an allegation of abuse involving Resident's #3 and #49 as required. This affected two (Resident's #3 and #49) and had the potential to affect all 88 residents residing in the facility. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/12/20 and diagnoses including bipolar disorder, schizophrenia, cerebral infarction, diabetes mellitus, major depressive disorder, hypertension, epilepsy, and personal history of adult physical and sexual abuse. Review of a quarterly Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 05/12/22, revealed Resident #3 had intact cognition. The assessment indicated Resident #3 was independent and required some staff set-up assistance with activities of daily living. Interview on 06/06/22 at 12:02 P.M. with Resident #3 revealed an allegation about Resident #49 who made negative comments to Resident #3 during the previous week at an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review the facility failed to ensure the care plans for Resident's #72 and #76 were comprehensive to include respiratory care and management. This affected two (Residents #72 and #76) reviewed for respiratory care. The facility reported 15 (Resident's #3, #10, #28, #31, #35, #56, #58, #59, #62, #63, #70, #72, #75, #76 and #85) who received respiratory care. The facility census was 88. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 10/21/20 and diagnoses of sleep apnea, morbid severe obesity due to excess calories, essential primary hypertension, need for assistance with personal care, and anxiety disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 had intact cognition. Resident #72 required extensive two staff assistance for bed mobility, dressing and toileting, extensive one staff assistance for personal hygiene, was dependent on two staff assistance for transfers,…

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 weekly weights were obtained per physician orders for three residents (Resident's #29, #31, #67) of nine residents reviewed for weekly weights. The facility census was 88. Findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses including COVID-19, bipolar disorder, schizophrenia, neuromuscular disorder of the bladder, mild intellectual disabilities, and hypothyroidism. Review of the physician's orders revealed on 05/20/22 weekly weights were ordered. Review of Resident #29's weights revealed his admission weight was 222.6 pounds and was not obtained until 03/29/22. His next weight was on 04/06/22 and was 217.0 pounds, on 05/04/22 his weight was 209.0 pounds, and then on 06/09/22 his weight was 200.2 pounds. Weights were not obtained per facility policy upon admission and weekly weights were not obtained as ordered on 05/20/22. 2. Resident #31 was admitted to the facility on [DATE] with diagnoses…

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

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed and dated per acceptable standards of nursing practice for Resident's #72 and #76. This affected two (Resident's #72 and #76) reviewed for respiratory care. The facility reported 15 (Resident's #3, #10, #28, #31, #35, #56, #58, #59, #62, #63, #70, #72, #75, #76 and #85) who received oxygen therapy. The facility census was 88. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 10/21/20 and diagnoses of sleep apnea, morbid severe obesity due to excess calories, essential primary hypertension, need for assistance with personal care, and anxiety disorder. Review of Resident #72's physician orders revealed an order dated 07/17/21 for oxygen at two liters per minute via nasal cannula (NC) every day and night shift related to hypoxemia. Observation on 06/06/22 at 11:23 A.M. revealed Resident #72's oxygen NC was not dated. Interview with Resident #72 at the time of the observation stated it was a long time ago when the oxygen tubing 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 policy review, the facility failed to ensure a clean and sanitary kitchen environment. This affected 94 residents of 94 residents receiving meals from the kitchen. The facility identified two residents, Resident #65 and Resident #87, as not receiving meals from the kitchen. The facility census was 96. Findings include: 1. Observation and tour of the kitchen with Dietary Manager (DM) #500 on 05/13/19 from 8:30 A.M. to 8:47 A.M. revealed inside the walk-in cooler, a bag of turkey slices dated 03/20/19; a bag of shredded cheddar cheese not wrapped, labeled or dated and left open to air; a bag of ham slices dated 04/19/19; and another bag of deli meat dated 05/06/19. Inside the walk-in freezer, two gallon plastic bags contained meatballs not labeled or dated. In the preparation area, the slicer and large mixer were unwrapped and not in use; the mixer had a twist tie inside of it. The top of the oven was covered in crumbs and grease. Interview with DM #500 verified the above…

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 comprehensive smoking policy was in place to address both smoking and non-smoking residents at the facility. This affected all 96 residents residing at the facility. Findings include: Observations of the facility's indoor smoking room on 05/13/19 and 05/14/19 during the annual survey revealed residents constantly going in and out of the room. A sign on the door of the smoking room indicated it was only closed for cleaning for part of the morning each day. No listed smoking times were observed. Interview on 05/14/19 at 2:11 P.M. with the Administrator revealed the indoor smoking room was open to residents 24 hours a day except for when it was closed for cleaning and verified there were no set smoking times at the facility. The Administrator shared supervised smokers went out to smoke every two hours but could not provide these times to the surveyor. The Administrator confirmed the facility smoking policy from December 2009 was the only policy available for review and verified this policy did not…

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 provide an acceptable noise level for the residents residing in the hall with the smoking room. This affected eight residents residing in the hall (Resident #12, Resident#13, Resident #15 Resident #25, Resident #44, Resident #56, Resident #63 and Resident #345). The facility census was 96. Findings include: Observation on the initial tour on 05/13/19 at 8:10 A.M. revealed an indoor smoking room with access to an unsecured outside area. A small detachable alarm was attached to the door to the smoking room and to the door outside. Both alarms emitted a loud high-pitched tone when activated to alert staff of residents exiting the building. There were buttons on the front of the alarms to punch in a code to void activation of the alarm. Residents entered and exited the smoking room freely at all times. A sign on the smoking room door stated the room was closed from 11:00 A.M. to 11:30 A.M. daily for cleaning. Intermittent observations 05/13/19 to 05/16/19 revealed the alarm was activated repeatedly by residents entering 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 interview and record review, the facility failed to report alleged misappropriation for Resident #59, and alleged verbal abuse from Resident #59 towards Resident #13. This affected two of two residents reviewed for abuse and misappropriation. The facility census was 96. Findings include: 1. Record review for Resident #59 revealed the resident was admitted on [DATE] with diagnoses including drug or chemical induced diabetes, attention deficit hyperactivity with alcohol abuse with alcohol induced anxiety disorder. Minimum Data Summary (MDS) 3.0 assessment of 03/31/19 revealed the resident was cognitively intact and independent for activities of daily living (ADL). Care plan of 03/14/19 revealed care areas for use of psychoactive medications, verbally abusive behavior (updated 05/13/19) and mood problems with goals and interventions appropriate to meet the needs of the resident. Interview with Resident #59 on 05/13/19 1:41 P.M. revealed the resident reported his cell phone went missing over the weekend.…

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 implement their policy for misappropriation. This affected one (Resident #59) of one resident reviewed for misappropriation. The facility census was 96. Findings include Record review for Resident #59 revealed the resident was admitted on [DATE] with diagnoses including drug or chemical induced diabetes, attention deficit hyperactivity with alcohol abuse with alcohol induced anxiety disorder. Minimum Data Summary (MDS) 3.0 assessment of 03/31/19 reveled the resident was cognitively intact and independent for activities of daily living (ADL). Care plan of 03/14/19 revealed care areas for use of psychoactive medications, verbally abusive behavior and mood problems with goals and interventions appropriate to meet the needs of the resident. Interview with Resident #59 on 05/13/19 1:41 P.M. revealed the resident reported his cell phone went missing over the weekend. The resident reported it to staff (unsure of the name), and they told him it was not their…

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 investigate and report alleged misappropriation for Resident #59, and failed to report alleged verbal abuse from Resident #59 towards Resident #13. This affected two of two residents reviewed for abuse and misappropriation. Findings include 1. Record review for Resident #59 revealed the resident was admitted on [DATE] with diagnoses including drug or chemical induced diabetes, attention deficit hyperactivity with alcohol abuse with alcohol induced anxiety disorder. Minimum Data Summary (MDS) 3.0 assessment of 03/31/19 revealed the resident was cognitively intact and independent for activities of daily living (ADL). Care plan of 03/14/19 revealed care areas for use of psychoactive medications, verbal abusive behavior (updated 05/13/19) and mood problems with goals and interventions appropriate to meet the needs of the resident. Interview with Resident #59 on 05/13/19 1:41 P.M. revealed the resident reported his cell phone went missing over the weekend.…

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 person-centered plan of care regarding resident behaviors. This affected one resident (Resident #24) of 24 residents reviewed for care planning. The facility census was 96. Findings include: Resident #24 was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, insomnia, atrial fibrillation, hypertension (high blood pressure), history of falls and constipation. Review of physician's orders revealed behaviors were to be documented every day shift and night shift. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired, had fluctuating inattention behaviors and had daily behaviors not directed towards others (like screaming or disruptive sounds). Resident #24 required extensive assistance for activities of daily living. A behavior care plan revised 04/08/19 revealed Resident #24 yelled out, Betty, Terry, or hey lady and did not…

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 policy review, the facility failed to ensure smoking materials were appropriately secured for both supervised and unsupervised smokers. This affected two residents (Resident #12 and Resident #13) of two residents reviewed for smoking. The facility identified 28 residents that smoked (Resident #1, Resident #5, Resident #6, Resident #7, Resident #12, Resident #14, Resident #15, Resident #16, Resident #19, Resident #25, Resident #26, Resident #33, Resident #35, Resident #36, Resident #37, Resident #44, Resident #45, Resident #48, Resident #54, Resident #57, Resident #59, Resident #60, Resident #63, Resident #70, Resident #83, Resident #90, Resident #345, Resident #395). The facility census was 96. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 09/20/17 with diagnoses including Alzheimer's disease, hypertension (high blood pressure), diabetes, hemiplegia affecting right dominant side and obesity. Review of a quarterly…

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 and interviews, the facility failed to adhere to infection control standards when serving meals and cleaning glucometers. This affected 5 (Residents #12, #13, #15, #61, and #63) of 5 residents observed during meal service and 1 (Resident #5) of 1 resident who receive blood sugar monitoring. Findings Include: 1. Observations with State Tested Nurse Assistant (STNA) #626 and Registered Nurse (RN) #601 were made on 05/13/19 at 2:15 P.M. and 2:30 P.M. STNA #626 was observed passing room trays to Residents #13, #15 and Resident #61 without sanitizing hands as they opened and closed resident doors, touched bed tables and opened the tray cart where trays are transported from kitchen. STNA #626 was also observed prepping Resident #61's sandwich without wearing gloves. Interview with STNA #626 after observations revealed that staff are to sanitize hands after delivering each tray and to wear gloves when touching food. The STNA did admit to not washing hands after leaving the residents room and touching the residents sandwich without wearing gloves. Observations with RN#…

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.