Winchester Terrace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to ensure wallpaper was not peeling and/or carpet was maintained in a clean manner/in good repair throughout the hallways of the facility. This had the potential to affect all 46 residents currently residing in the facility. Facility census was 46. Findings include: An environmental tour was conducted on 12/18/23 between 12:19 P.M. and 12:50 P.M. The tour revealed carpet in the hallways throughout the facility leading to resident rooms and other common resident areas contained multiple dark and light stains on dark blue carpet. There were many areas where the carpet fibers were missing. Interview on 12/18/23 at 12:20 P.M. with Housekeeper #103 revealed the sweeper sucks up a string of carpet and it keeps unraveling and [NAME] on the vacuum spool causing a bare spot revealing the carpet backing. The carpet was also noted in numerous areas to be pulling away from the floor in the center of the hallways that lead to resident rooms presenting 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 review of the facility funds management system, and resident, family and staff interviews, the facility failed to obtain written authorization prior to opening resident personal needs accounts. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37. Findings include: 1. Review of Resident #8's medical record identified admission to the facility occurred on 06/02/22. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was assessed with severely impaired cognition. Resident #8's payer source was listed as Medicaid. Review of Resident #8's personal needs account (PNA) revealed a balance on 03/31/23 of $700.15. There was no written authorization provided that indicated Resident #8 or a legal representative authorized for personal funds to be deposited in an account with the facility. 2. Review of Resident #16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility funds management system, and resident, family and staff interviews, the facility failed to provide quarterly statements of account activity and failed to maintain resident fund records in a clear and understandable manner. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37. Findings include: 1. Review of Resident #8's medical record identified admission to the facility occurred on 06/02/22. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was assessed with severely impaired cognition. Resident #8's payer source was listed as Medicaid. Review of Resident #8's personal needs account (PNA) revealed Resident #8 had a balance of $700.00 on 01/15/23 and on 03/31/23 was given interest brining the balance to $700.15. Further review of the account document revealed no monthly addition 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 call light audit documentation, medical record review, and resident and staff interview, the facility failed to ensure call lights were answered in a timely manner. This affected three (#5, #21, and #35) of five reviewed for call lights. The census was 37. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 02/28/23 with diagnoses including chronic kidney disease stage three, diarrhea, anxiety, hypertension, muscle wasting, need for personal assistance, hyperlipidemia, and benign prostatic hyperplasia. Review of the admission Minimum Data Set (MDS) assessment for Resident #5 dated 03/07/23 revealed Resident #5 was assessed with intact cognition and required extensive assist for activities of daily living (ADLs). Review of call light times for Resident #5 revealed a call light time of 250 minutes on 04/09/23 at 2:55 P.M. Interview on 04/13/23 at 9:39 A.M. with Resident #5 stated staff did not answer call lights very quickly and stated he often waits at least 30…

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 resident and staff interviews, the facility failed to bathe residents per their preference. This affected one (#2) of seven residents reviewed for bathing. The census was 37. Findings include: Review of Resident #2's medical record identified admission to the facility occurred on 02/07/23 with medical diagnoses including quadriplegia, high blood pressure, and pressure ulcers. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact. Review of section F of the MDS identified under the question how important it was for the resident to choose between a tub, shower, or bed bath, Resident #2 rated it was somewhat important on scale of one to five, with one being most important. The assessment further identified Resident #2 was totally dependant on staff for bathing. Review of Resident #2's written plan of care for activities of daily living (ADLs) dated 02/07/23 revealed he was totally dependent on staff for bathing,…

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, hospital discharge record review, and staff interview, the facility failed to confirmed a resident's code status upon admission to ensure accuracy. This affected one (#37) of 16 sampled residents reviewed for code status. The census was 37. Findings include: Review of Resident #37's medical record identified admission to the facility occurred on [DATE] with medical diagnoses including anemia, weakness, dementia, and history of falling. Review of Resident #37's discharge medical records from the hospital dated [DATE] revealed on [DATE] the hospital physician met with Resident #37's sister, and the hospital records revealed Resident #37 signed papers at the hospital to change his code status to Do Not Resuscitate (DNR) which instructed health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was assessed 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 observations, medical record review, and resident and staff interviews, the facility failed to provide adequate finger nail care for dependent residents. This affected two (#21 and #36) of four residents reviewed for activities of daily living (ADLs). The census was 37. Findings include: 1. Review of Resident #21's medical record identified the resident was admitted on [DATE] with medical diagnoses including falls, muscle weakness, high blood pressure, and coronary artery disease (CAD). Review of the admission comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was assessed with intact cognition and required extensive assistance of one person with personal hygiene. Review of Resident #21's written plan of care identified she was totally or nearly dependent on staff for bathing, hygiene, and dressing. Observation and interview with Resident #21 on 04/10/23 at 10:01 A.M. revealed Resident #21's finger nails were very long and some were jagged. Interview with Resident #21 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 observation, medical record review, resident and staff interview, and review of an activity calendar, the facility failed to ensure activities met the needs of the residents. This affected two (#10 and #24) of 13 residents reviewed for activities. The census was 37. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 09/10/21 with diagnoses including rheumatoid arthritis, atrial fibrillation, morbid obesity, nonrheumatic mitral valve insufficiency, major depressive disorder, fibromyalgia, osteoarthritis, unspecified psychosis, anxiety, hypertension, and gastroesophageal reflux disease. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 01/12/23 revealed Resident #10 was assessed with intact cognition and required extensive assist for activities of daily living (ADLs). Review of the care plan for Resident #10 dated 01/12/23 revealed the resident was very active in activities. Resident enjoyed BINGO, crafting, and cooking activities. Interventions included encourage ongoing family involvement, invite 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 observations, medical record review, and staff interviews, the facility failed to provide pressure ulcers prevention interventions as indicated. This affected one (#36) of two residents reviewed for pressure ulcers. The census was 37. Findings include: Review of Resident #36's medical record identified admission to the facility occurred on 02/25/23 under the care of hospice services for end of life care. Resident #36 had medical diagnoses including dementia, anxiety, restlessness and agitation. Review of Resident #36's admission Minimum Data Set (MDS) assessment dated [DATE] identified no skin issues at the time of admission; however, Resident #36 was identified at high risk for pressure ulcer development. Review of Resident #36's plan of care included a pressure reducing mattress. Review of Resident #36's medical record revealed on 03/27/23 Resident #36 was seen by a wound consultant for development of a pressure ulcer to the coccyx. The wound consultant note dated 03/27/23 identified Resident #36's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to provide nutritional interventions as ordered. This affected one (#92) of two residents reviewed for nutrition. The census was 37. Findings include: Review of Resident #92's medical record identified admission occurred on 03/22/23. Resident #92 was placed on hospice services on 04/07/23 with medical diagnoses including; COVID-19, dementia, pulmonary nodules, and history of colon cancer. Review of Resident #92's nutritional admission assessment dated [DATE] revealed Resident #92 had a poor appetite and a physician order was placed to provide yogurt daily at breakfast. Further review revealed Resident #92's family indicated Resident #92 liked yogurt and would usually eat it. Review of Resident #92's admission weight on 03/28/23 revealed Resident #92 weighed 98 pounds. Observation of Resident #92 on 04/11/23 at 9:05 A.M. revealed Resident #92 was assisted with eating by State Tested Nurse Aide (STNA) #67 with no yogurt present.…

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 residents were free from significant medication errors. This affected one (#12) of four residents reviewed for medications. The census was 37. Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/20/12 with diagnoses including cerebral infarction, flaccid hemiplegia affecting right dominant side, aphasia, major depressive disorder, hypothyroidism, anxiety, Bell's palsy, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was assessed with moderately impaired cognition. Review of a nurses note dated 04/06/23 revealed Resident #12 had new orders for the thyroid hormone levothyroxine (Synthroid) 200 micrograms (mcg), the cholesterol-lowering medication fenofibrate 145 milligrams (mg), and laboratory values on 07/06/23. Review of the April 2023 medication administration record (MAR) for Resident #12 revealed levothyroxine 175 mcg 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, resident, family, and staff interviews, and medical record review, the facility failed to timely follow up with dental services after a resident's dentures were lost. This affected one (#21) of seven residents reviewed for dental services. The census was 37. Findings include: Review of Resident #21's medical record identified admission to the facility occurred on 02/13/23 with medical diagnoses including falls, muscle weakness, chronic obstruction pulmonary disease (COPD), and high blood pressure. Review of Resident #21's admission assessment dated [DATE] revealed Resident #21 had upper and lower dentures. Review of Resident #21's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact, required extensive assistance of one person for personal hygiene, and was assessed with no broken or loosely fitting dentures. The assessment identified Resident #21 would not be able to obtain her dentures without assistance from the staff. Observation 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.

Based on observation, staff, resident and family interviews, review of a resident notice, review of a nursing services sign, review of a letter addressed to the Ohio Department of Health, review of the resident council minutes and policy review, the facility failed to ensure the resident call light system was timely repaired. This had the potential to affect all 43 residents residing in the facility. The facility census was 43. Findings include Observation on 12/02/19 beginning at 9:00 A.M. revealed the resident call light system was not functioning. Further observations revealed residents were given a metal call bell to ring when assistance was needed. Continued observations revealed notices Important Notice Call Light System were posted in resident rooms. Review of the undated Important Notice Call Light System, revealed the call light system went down and was beyond repair. Everything was in motion to get the system replaced as quickly as possible. Further review of the notice revealed each resident had a service bell to ring for assistance and to ring the bell multiple times so…

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, observations, staff, resident and family interview, review of the facility activity calendar and policy review, the facility failed to provide a program of activities that met the residents needs and interests. This affected six (#20, #2, #38, #31, #7 and #37) of six residents reviewed for activities. The census was 43. Findings include: 1. Review of Resident #20's medical record revealed he admitted to the facility on [DATE]. Diagnoses included cerebral infarction, major depressive disorder, and anxiety. Review of Resident #20's Minimum Data Set (MDS), dated [DATE], revealed he had a moderate cognitive impairment and was totally dependent on staff for bathing. The MDS revealed doing his favorite activities was very important. Review of Resident #20's activity care plan, last revised 09/23/19, revealed he had a potential for altered mood/psychosocial deficit related to nursing home placement as well as diagnoses of depression and anxiety. The care plan stated Resident #20's…

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

Based on observation, interview with facility staff, and review of a kitchen cleaning calendar, the facility failed to maintain the kitchen food preparation area and five oven its in a sanitary condition. This had the potential to affect all but one resident (#10-cannot consume oral nutrition). The census was 43. Findings include: During an observation on 12/02/19 at 9:15 A.M., the kitchen floor in the food preparation area had a black and sticky residue. The preparation area was several feet long, and its entirety was soiled. Interview on 12/02/19 at 9:15 A.M. with Dietary Aid (DA) #39 confirmed the food preparation area had a black and sticky residue. She stated it had looked like this when she arrived for her shift that morning. She stated staff was supposed to mop the preparation area after dinner and must not have mopped 12/01/19. During an observation on 12/02/19 at 9:17 A.M., five oven mitts were hanging by the oven and microwave and appeared brown and soiled. Some of the fibers of the mitts were matted together. Interview on 12/02/19 at 9:17 A.M. with DA #39 confirmed five…

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, observations, staff and resident interviews and review of the Resident [NAME] of Rights, the facility failed to ensure residents were afforded with their right to dignity. This affected two (#20 and #13) of two residents reviewed for dignity. This had the potential to affect all residents. The census was 43. Findings include: 1. Review of Resident #20's medical record revealed he admitted to the facility on [DATE]. Diagnoses included cerebral infarction, major depressive disorder, and anxiety. Review of Resident #20's Minimum Data Set (MDS), dated [DATE], revealed he had a moderate cognitive impairment and was totally dependent on staff for bathing and locomotion. The MDS revealed doing his favorite activities was very important. Review of Resident #20's activity care plan, last revised 09/23/19, revealed he had a potential for altered mood/psychosocial deficit related to nursing home placement as well as diagnoses of depression and anxiety. The care plan stated Resident #20's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to complete Advanced Beneficiary Notices (ABN) as required for two (#33 and #248) of two residents reviewed who remained in the facility after being cut from skilled services and still had remaining Medicare Benefit days available for use. The facility identified two (#33 and #248) who had had remained in the facility after being discharged from skilled care and had remaining Medicare Benefits remaining in the last 180 days. Facility census was 43. Findings include: 1. Review of Resident #33's medical record revealed she admitted to the facility 08/03/19. Diagnoses included dementia with behavioral disturbance. Review of Resident #33's Minimum Data Set (MDS), dated [DATE], revealed she had a severe cognitive impairment and required extensive assistance from staff for ADL's. Review of a form titled, Beneficiary Notice-Residents discharged Within the Last Six Months, revealed she was discharged from skilled services on 08/30/19.…

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, resident and family interview and review of resident council minutes, the facility failed to ensure an adequate supply for towels and washcloths were available for resident use. This affected three (#18, #1 and #37) out of 17 residents sampled during the survey. The facility census was 43. Findings include: Interview on 12/04/19 at 12:10 P.M. with Resident #37's husband stated the facility did not have any clean washcloths or towels last night to provide care for the resident. Observation on 12/04/19 at 2:06 P.M. of the facility's laundry room and linen closets revealed no wash clothes or towels in the two linen closets and currently a load of washcloths and towels in the dryer. Observation on 12/05/19 at 9:28 A.M. of the facility's two linen closets revealed only two towels available for resident use. Interview on 12/04/19 at 1:58 P.M. with State Tested Nursing Assistants (STNA's) #48 and #71 verified they had limited clean laundry this morning to provide care with. Interview on 12/04/19 at 2:06 P.M. with Laundry/Housekeeping Supervisor #38 verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to accurately code the Minimum Data Set (MDS) assessment. This affected two (#2 and #44) of 14 residents reviewed for accurate MDS assessments. The census was 43. Findings include: 1. Review of Resident #2's medical record revealed she admitted to the facility on [DATE]. Diagnoses included major depressive disorder, aphasia following cerebral infarction, and hemiplegia/hemiparesis following cerebral infarction. Review of Resident #2's Minimum Data Set (MDS) dated [DATE], section B of the MDS, which assessed vision, speech, and hearing, revealed she was sometimes understood and sometimes understands others. Section C of the MDS which assessed cognition stated an interview should not be conducted because resident was rarely/never understood. A staff assessment was completed and revealed Resident #2 had a severe cognitive impairment. She had no behaviors per the MDS. Further review of the MDS revealed Resident #2…

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 medical record review and staff interview, the facility failed to screen two residents for serious mental illness and developmental disability prior to admission. This affected two (#1 and #43) of 14 residents reviewed for appropriate Pre-admission screens. The census was 43. Findings include: 1. Review of Resident #1's medical record revealed she admitted to the facility 08/15/19. Diagnoses included cerebral palsy, major depressive disorder, and schizophrenia. Review of her Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required extensive assistance from staff with activities of daily living. Review of the medical record lacked evidence of a pre-admission screen. During an interview on 12/02/19 at 3:34 P.M., Office Manager (OM) #57 confirmed Resident #1's Pre-admission Screen/Resident Review did not include her schizophrenia nor cerebral palsy, and thus was not properly screened for serious mental illness or developmental disability and should have been as the boards of both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident, family and staff interviews and review of facility policy, the facility failed to ensure showers were provided to a resident who required assistance with activities of daily living. This affected one (#43) of two residents reviewed for showers. The facility census was 43. Findings include Review of the medical record revealed Resident #43 had an admission date of 11/08/19. Diagnoses included a malignant neoplasm of the ovary, cerebral infarction, pleural effusion, cachexia, atrial fibrillation, difficulty walking, osteoarthritis and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had mild cognitive impairment. Further review of the MDS assessment revealed Resident #43 was dependent on staff for bathing. Continued review of the MDS assessment revealed it was very important for Resident #43 to choose between tub bath, shower, bed bath or sponge bath. Review of the shower schedule revealed Resident #43's name was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and resident and staff interviews, the facility failed to ensure a resident's hearing aid was maintained. This affected one (#26) of eight residents who wear hearing aids. The facility census was 43. Findings include: Review of Resident #26's medical record revealed an admission date of 08/28/14. Diagnoses included multiple sclerosis, trigeminal neuralgia, unspecified hearing loss, glaucoma, and peripheral vascular disease. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment listed the resident as having moderate difficulty with hearing. Review of Resident #26's care plan revealed a communication deficit related to hearing loss. Interventions included to refer for audiology evaluation as needed. Review of Resident #26's social services note dated 07/24/19 revealed an Audiologist visited to deliver a hearing aid for the resident's right ear. The resident was instructed to wear the hearing…

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 and interview with facility staff, the facility failed to provide preventative pressure ulcer interventions as care planned and physician ordered. This affected one (#2) of two residents reviewed for skin. The facility identified 36 residents receiving preventative skin care. Facility census was 43. Findings include: Review of Resident #2's medical record revealed she admitted to the facility on [DATE]. Diagnoses included major depressive disorder, aphasia following cerebral infarction, and hemiplegia/hemiparesis following cerebral infarction. Review of Resident #2's Minimum Data Set (MDS) dated [DATE], section B of the MDS, which assessed vision, speech, and hearing, revealed she was sometimes understood and sometimes understands others. Section C of the MDS which assessed cognition stated an interview should not be conducted because resident was rarely/never understood. A staff assessment was completed and revealed Resident #2 had a severe cognitive impairment. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident, family and staff interviews and review of facility policy, the facility failed to monitor a resident's weights weekly and failed to administer nutritional supplements per physician orders for a resident who was assessed as experiencing a significant weight loss before admission. This affected one (#43) of one resident reviewed for nutrition. The facility identified six residents at high risk for malnutrition and 25 residents receiving nutritional supplements. The facility census was 43. Findings include Review of the medical record revealed Resident #43 had an admission date of 11/08/19. Diagnoses included a malignant neoplasm of the ovary, cerebral infarction, pleural effusion, cachexia, atrial fibrillation, difficulty walking, osteoarthritis and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had mild cognitive impairment. Review of weight documentation revealed Resident #43 weighed 109 pounds on 11/14/19.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and review of facility policy, the facility failed to ensure the 13-valent pneumococcal vaccine (Prevnar-13) was offered to the residents. This affected three (#7, #20, #26) of five residents reviewed for influenza and pneumococcal vaccinations. The facility census was 43. Findings include 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included dementia and hypertension. Review of immunization documentation revealed no documentation Resident #7 was offered or had received the Prevnar-13 pneumococcal vaccine. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included, cerebral infarction and hypertension. Review of immunization documentation revealed no documentation Resident #20 was offered or had received the Prevnar-13 pneumococcal vaccine. 3. Review of the medical record revealed Resident #26 had an admission date of 08/28/19. Diagnoses included…

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