Phoenix Of Maple Heights

Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in Resident #26's mental health condition as required. This affected one resident (#26) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/06/16. Diagnoses included but were not limited to delusional disorder, depression, vascular dementia, and mood disorder. Review of the 12/29/2017 facility PASARR Identification Screen for Resident #26 revealed it was the most recent PASARR completed. Under section D indications of serious mental illness revealed a diagnosis of delusional (paranoid) disorder and psychiatric services had been utilized within the past two years due to mental disorder. Review of Resident #26's medical diagnoses revealed a diagnosis of schizoaffective disorder on 03/30/21 was added. Review of both the electronic and paper chart revealed no evidence 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 medical record review, observation, interview, and facility policy review the facility failed to ensure comprehensive care plans were created for Resident #26, #63, and #72. This affected three residents (#26, #63, and #72) of three residents reviewed for care plans. The facility census was 88. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 07/06/16. Diagnoses included but were not limited to delusional disorders, depression, vascular dementia, osteoarthritis, morbid obesity, gastro esophageal reflux disorder, and schizoaffective disorder. Resident #26 was noted to be cognitively intact and require supervision for eating and oral hygiene. No evidence was found related to a dental care plan to address dental issues. Review of the facility resident dental list for the past twelve months revealed Resident #26's last dental visit was 06/27/23. Review of the 6/27/23 dental summary report for Resident #26 revealed partial dentition, and multiple root tips…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #67 had orders to care for a urostomy and failed to ensure supplies were available. This affected one resident (#67) of one resident who received ileostomy and colostomy care. The facility census was 88. Findings include: Review of the medical record for Resident #67 revealed an admission date of 03/29/24 with diagnoses including history of other infectious and parasitic disease, pressure ulcer of sacral region, pressure ulcer right heel, colostomy status, artificial opening of the of the urinary tract, chronic kidney disease, and malignant neoplasm of the endometrium, the lining of the uterus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 had intact cognition and had an ostomy. The resident was required substantial to maximum assistance with toileting. Review of the care plan dated 04/05/24 revealed Resident #67 had alterations in elimination related to 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, record review, and facility policy review the facility failed to ensure Resident #12 had current oxygen orders and an oxygen care plan and failed to ensure portable oxygen tanks were secured. This affected one resident (#12) of ten residents receiving oxygen. The facility census was 88. Findings include: Review of the medical record for Resident #12 revealed an admission date of 05/21/15 with diagnoses including acute kidney failure, dementia, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition and required substantial to maximal assistance for transfers, hygiene, and dressing. The assessment stated the resident was not receiving oxygen therapy. Review of the care plan dated 03/12/24 revealed Resident #12 did not have an oxygen care plan. Review of the profile computer tab revealed a picture of Resident #12 wearing a nasal canula for oxygen. Review of the physician orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #63. This affected one resident (#63) of one resident residing at the facility receiving dialysis. The facility census was 88. Findings include: Review of the medical record for Resident #63 revealed an admission date of 08/19/23. Diagnoses included but were not limited to end stage renal disease, dependence on renal dialysis, congestive heart failure, and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was receiving dialysis treatments. Review of the facility pre and post dialysis assessments for Resident #63 for the month of April, May, and June of 2024 revealed no documented evidence of pre and post assessments for 04/01/24, 04/03/24, 04/05/24, 04/08/24, 04/10/24, 04/12/24, 04/15/24, 04/17/24, 04/19/24, 05/01/24, 05/08/24, 05/10/24, 05/13/24; no documented evidence 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 observation, interview, and record review, the facility failed to monitor resident behaviors, develop resident centered care plans with interventions specific for the resident's behaviors, or implement interventions when behaviors occurred for Resident #72. This affected one resident (#72) of two residents reviewed for behavioral health. The facility census was 88. Findings Include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder (a condition in which a patient intentionally falsifies medical or psychiatric symptoms and can be self-induced or fabricated), and mood disorder. Review of the physician's orders for Resident #72 dated 06/23/23 was an order to document resident's behaviors every shift. Review of the Medication Administration Record (MAR) for April, May, and June 2024 for Resident #72 revealed the resident refused all medications every day. Behavior…

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

Based on medical record review, ancillary services appointment lists, interviews, and facility policy review the facility failed to ensure dental services were provided to Resident #26 as needed. This affected one resident (#26) of one resident reviewed for dental services. The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/06/16. Diagnoses included but were not limited to delusional disorders, depression, vascular dementia, osteoarthritis, morbid obesity, gastro esophageal reflux disorder, and schizoaffective disorder. Resident #26 was noted to be cognitively intact and require supervision for eating and oral hygiene. No evidence was found related to a dental care plan to address dental issues. Review of the facility resident dental list for the past twelve months revealed Resident #26's last dental visit was on 06/27/23. Review of the 06/27/23 dental summary report for Resident #26 revealed partial dentition, and multiple root tips needed to be extracted. An oral surgery referral was noted to be written to 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 record review, observation, interview, and facility policy review the facility failed to ensure call lights were functional and in reach for Residents #5, #12, and #13. This affected three residents (#5, #12 and Resident #13) of 88 residents reviewed for call lights. The facility census was 88. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 05/21/15 with diagnoses including acute kidney failure, dementia, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition and required substantial to maximal assistance for transfers, hygiene, and dressing. The resident was dependent for transferring. Review of the care plan dated 03/12/24 revealed Resident #12 had a self-care deficit related to weakness and behaviors. Interventions included one staff for assistance with dressing, eating, and toileting. 2. Review of the medical record for Resident #13 revealed 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 observation, record review, interview and facility policy review, the facility failed to ensure Resident #35's bilateral lower extremity non-pressure wound care was completed as ordered by the physician. This finding affected one resident (#35) of three residents reviewed for wounds. Findings include: Review of the medical record revealed Resident #35 was readmitted on [DATE] with diagnoses including partial traumatic amputation of the left foot, sepsis, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 exhibited moderate cognitive impairment. Review of Resident #35's physician orders revealed an order dated 04/17/24 to cleanse the bilateral lower extremities with normal saline, apply collagen powder to the wound bed followed by Xeroform (non-adherent dressing) and cover with a four-by-four gauze and wrap with Kerlix gauze once every two days. Review of the Medication Administration Records (MARS) and Treatment Administration…

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

Based on observation, interview and review of facility policy, the facility did not ensure facility air temperatures were maintained between 71 to 81 degrees Fahrenheit (F). This affected all 87 residents residing in the facility. The facility census was 87. Findings include: Observation on 03/26/24 at 4:00 P.M. revealed nursing staff throughout the facility had various cooling fans running and housekeeping employees were profusely sweating while cleaning rooms on the 200 unit. Observations on 03/26/24 from 4:00 P.M. until 4:45 P.M. revealed the end of the 200 hall the air temperature was 84.9 degrees F and observation of three resident rooms on the 200 unit revealed ambient air temperatures were between 82.2 and 83.9 degrees F. Interview on 03/26/24 at 4:01 P.M. with Resident # 45 revealed they felt hot in their room. Interview on 03/26/24 at 4:05 P.M. with Resident # 42 stated they felt a little hot. Interview on 03/26/24 at 4:10 P.M. with Housekeeper #386 revealed they felt overheated while cleaning resident rooms because the facility felt too warm. Interview on 03/26/24 at 10:00…

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

Based on observation and interview the facility failed to ensure adequate food temperatures. This had the potential to affect to all residents that resided in the facility. The facility census was 91. Findings include: Interview on 11/28/23 at 9:30 A.M. with Resident #64 revealed her meals were always cold. Interview on 11/28/23 at 10:31 A.M. with Residents #53 and #54 revealed their meals were always cold. Interview on 11/28/23 at 11:40 A.M. with Chef #215 revealed he was aware of residents concerns regarding food temperatures. Chef #215 stated the temperatures were taken prior to the trays leaving the kitchen. The facility did not have heated food boxes for transporting meals. Observation of food temperatures being obtained at time of interview revealed the rigatoni was 149 degrees Fahrenheit (F), sausage and peppers were 171 degrees F and the broccoli was 181 degrees F. A test tray left the kitchen at 12:08 P.M. and was on the floor at 12:10 P.M. At 12:35 P.M., after all residents were served the test tray was completed. The rigatoni was 109 degrees F, the sausage and peppers…

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 accurately document the times medication was administered. This affected three of three residents (#62, #63 and #64) reviewed for medication administration documentation. The facility census was 91. Findings include: 1. Review of Resident #62's physician orders for November 2023 revealed an order for Aricept (used to treat dementia) 10 milligrams (mg) at 7:00 A.M. Review of the Medication Administration Record (MAR) for November 2023 revealed Aricept 10 mg was documented as administered on 11/01/23 at 2:45 P.M., 11/02/23 at 12:43 P.M., 11/05/23 at 1:15 P.M., 11/09/23 at 6:00 P.M., 11/16/23 at 3:35 P.M. and 11/28/23 at 12:32 P.M. 2. Review of Resident #63's physician orders for November 2023 revealed orders for benzotropine (used to treat Parkinson's disease) 2 mg at 7:00 A.M., and Depakote (seizure medication) 125 mg at 7:00 A.M. Review of the MAR for November 2023 revealed benzotropine and Depakote were documented as administered on 11/01/23 at 2:46 P.M., 11/03/23 at 11:37 A.M., 11/07/23 at 11:19 A.M., 11/09/23 at 5:51…

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

Based on observation, record review and interview, the facility failed to ensure that one resident (Resident #4) was served their lunch meal at the same time as the other residents seated at the dining table. This affected one (Resident #4) of three (Resident #55 and Resident #57) seated at a table in first floor dining room. The facility census was 92. Findings included: Observation of lunch service on 04/26/22 at 12:05 P.M. in the first-floor dining room, Resident #4 was observed seated at a table with two other residents (Resident #55 and Resident #57). Resident #55 and Resident #57 had their lunch trays and were eating their meals. Resident #4 did not have her lunch meal. Other residents seated in the dining room continued to receive their meals. During continued observation from 12:05 P.M. to 12:35 P.M., Resident #4 remained seated at the dining table without her lunch tray. Resident #57 completed her meal at 12:25 P.M. Resident #4 did not receive her lunch tray until 12:35 P.M. Review of Resident #4's medical record indicated an admission date of 09/04/19. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accurate advance directive orders matched throughout the medical record for Resident #42. This affected one of 24 residents reviewed for advanced directives. The facility census was 92. Findings include: Resident #42's was admitted to the facility on [DATE] with diagnoses that included dementia, bipolar, and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition and received hospice care. Review of the electronic medical record (EMR) physician's orders revealed an order dated [DATE] for a full code status (meaning to initiate cardiopulmonary resuscitation (CPR) if no heartbeat.) Review of the signed physicians' order for [DATE] revealed Resident #42 had a full code status. Review of the hard medical chart for Resident #42 revealed a signed Do Not Resuscitate Comfort Care (DNRCC) code status (meaning any care that eases pain and suffering but no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure nail care was provided. This affected three (Resident #37, Resident #53, and Resident #58) out of five residents (Resident #8 ad Resident #42). The facility census was 92. Findings Include: 1. Review of the open record of Resident #37 revealed he was admitted to the facility on [DATE] and then readmitted on [DATE]. His admitting diagnoses included major depressive disorder, type II diabetes, dementia, severe protein calorie malnutrition, bipolar disorder and fracture of the neck of the left femur. Review of this resident's Minimum Data Set assessment dated [DATE] revealed this resident was alert and oriented times three. Review of his of activities of daily living revealed he needed supervision with set up for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Observation on 04/26/22 at 8:00 A.M. revealed the resident was appropriately dressed. The resident stated his showers were on time and as he liked. It was noted 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 and interview the facility failed to ensure the medical supplies inside the treatment cart were not expired, and failed to ensure medications opened were dated with the date they were opened. This has the potential to affect 14 residents (Resident #6, Resident #7, Resident #17, Resident #23, Resident #27, Resident #33, Resident #35, Resident #56, Resident #61, Resident #84, Resident #86, Resident #87, Resident #90 and Resident #292); three residents (Resident #15, Resident #43, Resident #87) out of three residents reviewed for insulin not dated and for eye drops not dated when opened; and it had the potential to affect five residents (Resident #18, Resident #33, Resident #52, Resident #80 and Resident #90) out of five residents reviewed for expired medications/supplies. The facility census was 92. Findings Include 1. Observation of the cart on 04/26/22 at 8:30 A.M. revealed the cart contained a small box of Epsom salts opened with an expiration date of 04/19; one Intravenous start kit dated 02/28/22; 2 Puertane Virus Trap Systems dated 10/30/19; Ammonia Lactate…

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 the dining room chairs were safe and in good working order. This had the potential to affect nine residents (Resident #13, #14, #16, #18, #20, #24, #40, #64 and #74) who used chairs in the dining room. The facility census was 92. Findings include: Observation on 04/26/22 at 12:15 P.M. of the second-floor dining room revealed three chairs with broken and cracked wooden supports. One chair was turned facing the wall and two chairs were placed at tables. Interview and observation on 04/26/22 at 12:28 P.M. with Minimum Data Set (MDS) Nurse #601 verified the above findings and revealed she was unaware of the three broken chairs in the dining room. MDS nurse #601 stated the facility had ordered new chairs that were arriving soon. MDS Nurse #601 removed two of the three broken chairs out of the dining room. Interview on 04/28/22 at 4:50 P.M. with the Maintenance Director #602 revealed he was new to the job and had not conducted any environmental rounds to ensure equipment is in working order. Review of the facility's policy…

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

Based on observation and interview, the facility failed to ensure staff used a beard restraint when preparing and plating food for residents to prevent hair from contaminating food during meal service. This finding had the potential to affect all seventy residents residing in the facility who received meals from the kitchen and the dining rooms. Findings include: 1. Observation on 03/25/19 at 12:08 P.M. revealed Dining Aide (DA) #401 was in the main dining room on the first floor plating food from a steam table for resident consumption and the staff member had a black beard with no beard restraint in place. Observation on 03/26/19 at 8:40 A.M. revealed DA #401 was in the main dining room on the first floor plating food from a steam table for resident consumption and the staff member had a black beard with no beard restraint in place. Interview on 03/26/19 at 9:20 A.M. with DA #401 confirmed he was aware that he should have had a beard restraint in place however his chin was irritated and he did not want to wear one. 2. An observation of puree food preparation in the kitchen 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 interview and record review, the facility failed to establish an effective infection prevention, control and monitoring program. This had the potential to affect all 70 residents who resided in the facility. Findings include: An interview with the Director of Nursing (DON) on 03/28/19 at 1:30 P.M. revealed she was the infection control designee for the facility. She provided three months of her tracking for infections and antibiotic use in the facility. She stated she had started her position in January 2019 and did not have the tracking or any information regarding infection control tracking prior to January 2019. Review of the information provided by the DON for January 2019 revealed eight entries for residents who had received antibiotics for the month on a form titled, Antibiotic Use Tracking Sheet. For February and March 2019 (through the date of the survey), the tracking sheets indicated four residents had received antibiotics for those months. The DON also provided, Monthly Reports of Facility Infections, which contained a breakdown for the months of January,…

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 an effective antibiotic use and monitoring program. This had the potential to affect all 70 residents who resided in the facility. Findings include: An interview with the Director of Nursing (DON) on 03/28/19 at 1:30 P.M. revealed she was the infection control designee for the facility. She provided three months of her tracking for infections and antibiotic use in the facility. She stated she had started in her position in January 2019 and did not have any of the tracking or information regarding infection control prior to January 2019. Review of the information provided by the DON for January 2019 revealed eight entries for residents who had received antibiotics for the month on a form titled, Antibiotic Use Tracking Sheet. For February and March 2018 (through the date of the survey), the tracking sheets indicated four residents had received antibiotics for those months. The DON also provided, Monthly Reports of Facility Infections, which contained a breakdown for January, February and March 2019. The January 2019…

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

Based on observation, record review and interview, the facility failed to ensure a clean and sanitary smoking area. This finding affected Resident #268 and had the potential to affect all twenty-four smokers (Residents #1, #4, #5, #20, #24, #26, #27, #33, #34, #35, #39, #40, #41, #42, #47, #48, #50, #52, #53, #59, #63, #65, #267 and #268) who reside in the facility and smoke in the courtyard. The facility census was 70. Findings include: Observation on 03/25/19 at 10:07 A.M. with State Tested Nursing Assistant (STNA) #405 revealed residents were allowed in the courtyard for a designated smoke break. Further observation revealed the courtyard had a large amount of cigarette butts on the cement and grass areas of the courtyard. Interview with STNA #405 at the time of the observation revealed the residents sometimes cleaned up the courtyard. Observation on 03/26/19 at 10:45 A.M. with STNA #405 revealed the smoking courtyard area had a large amount of cigarette butts in the grass area of the courtyard. Interview at the time of the observation with STNA #405 indicated staff would try 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 record review and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This finding affected five (Residents #22, #33, #46, #47 and #57) of twenty-one residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, end stage renal (kidney) disease and type two diabetes. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. This assessment indicated Resident #46 received three doses of an antianxiety medication in the seven day look back period of 02/07/19 to 02/13/19. Review of Resident #46's physician orders revealed an order dated 11/28/18 for Lorazepam (an antianxiety medication), 0.5 mg (milligrams), give one tablet by mouth every day for dialysis days on Tuesday, Thursday and Saturdays. Review…

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 accurately inform residents of their discharge date s from Medicare Part A affecting Residents #270, #272 and #273. This affected three of four residents reviewed for beneficiary notifications. Findings Include: 1. Resident #270 was admitted to facility on 07/03/18. Her clinical census report revealed her last covered day (LCD) of Medicare A as 07/24/18 and Medicaid would start on 07/25/18 as a payment source. Resident #270 was issued a Notice of Medicare Non-Coverage form (NOMNC) for a LCD of 07/30/18 and it was signed by Resident #270 on 07/27/18. Further review of Resident #270's record revealed a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). It was issued with a start date of 07/30/18 and was signed by Resident #270 on 07/27/18. Interview on 03/27/19 at 6:01 P.M. with the Administrator and Social Service Designee (SSD) #407 revealed SSD #407 was notified by Physical Therapy of residents LCD and she will initiate the NOMNC, and SNF ABN if required, with the resident, or family, or…

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 develop a comprehensive, resident centered care plan for Resident #53 regarding urinary/bladder infections and his need to self-catheterize. This affected one of two residents reviewed for catheters. The facility census was 70. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including diabetes, cystitis (a urinary tract infection), hematuria (blood in the urine) and paraplegia. The resident had a history of bladder and urinary tract infections. Review of his most recent quarterly minimum data set assessment dated [DATE] revealed he was alert, oriented and cognitively intact. An interview with Resident #53 on 03/26/19 at 9:34 A.M. revealed he performed self-catheterizations (procedure involving the insertion of a tube into the bladder to empty urine) four to five times daily. He stated he had done this for years. He indicated he had told facility staff several days prior that he…

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 #2's neurological examinations were completed as required after an unwitnessed fall. This finding affected one of five residents reviewed for accidents. Findings include: Resident #2 was admitted to facility on 10/19/16 with diagnoses including heart failure, hypertension, atrial fibrillation and schizoaffective disorder, bipolar type. His care plan, dated 12/15/18, revealed he was at increased risk for falls. Interventions included fall risk standard precautions and for staff to increase safety monitoring. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of zero, scores of zero to seven indicate severe cognitive impairment. Review of Progress Notes revealed Resident #2 had an unwitnessed fall on 12/30/18. Resident #2 was assessed for injuries and a 4.0 centimeter (cm) wide and 1.5 cm deep laceration was discovered on the front of his right lower leg. He was sent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #36's catheter was changed according to the physician orders. This affected one of two resident reviewed for urinary catheters. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, urinary tract infection and unspecified dementia without behavioral disturbance. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and had an indwelling urinary or Foley catheter, a tube inserted into the bladder to drain urine. Review of Resident #36's physician orders revealed an order dated 01/24/19 to change the Foley catheter every two weeks. Review of Resident #36's treatment administration records (TARS) from 02/01/19 to 03/27/19 revealed the resident's catheter was last changed on 02/21/19 and was required to be changed again on 03/07/19 and 03/21/19. 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 #46's arteriovenous (AV) fistula (a vascular access device surgically created for kidney dialysis) was monitored according to the physician orders. This finding affected one of one resident reviewed for dialysis. Findings include: Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, and end stage renal (kidney) disease. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #46's physician orders revealed a order dated 02/09/13 for nursing staff to check the left upper extremity/arm AV fistula site for bruit and thrill every shift. A bruit is a swishing sound heard when a stethoscope is placed on the AV fistula and a thrill is the vibration felt on the AV fistula. Checking for the bruit and the thrill ensure the AV…

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 vital signs were checked as ordered prior to the administration of a blood pressure medication for Resident #47. This affected one of five residents reviewed for unnecessary medications. Findings include: Review of the record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, diabetes mellitus, weakness, dementia and a history of stroke. Review of physician orders revealed Coreg, a blood pressure medication, was ordered on 09/27/18 and was to be administered twice a day to Resident #47. Review of the pharmacy recommendation dated 03/07/19 revealed a recommendation for a blood pressure and pulse be checked prior to the administration of Coreg, one of several blood pressure medications taken by Resident #47. The recommendation was approved by the physician and the physician wrote an order on 03/21/19 which directed nursing staff to hold the blood pressure medication if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #366's medications were administered according to the physician orders and with an error rate of less than 5% (percent). This finding affected one (Resident #366) of five residents observation for medication administration. A total of 26 medications were administered with two errors resulting in a medication error rate of 7.69%. Findings include: Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin Resistant Staphylococcus aureus infection, septic pulmonary embolism (blood clot in the lung) and low back pain. Review of Resident #366's physician orders revealed an order dated 03/21/19 to infuse Vancomycin (an antibiotic) 1.25 grams (gm) via intravenously (IV) every twelve hours, due at 8:00 A.M. and 8:00 P.M. Review of Resident #366's physician orders revealed an order dated 03/07/19 for Humalog insulin (fast acting insulin), eight units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure expired medications were discarded appropriately. This finding affected three (Residents #17, #53 and #55) of three residents whose insulin was stored in the two front hall medication storage cart. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with other diabetic kidney complications, conduct disorder and bipolar disorder. Review of Resident #21's physician orders revealed an order dated 07/28/18 for Humulin N insulin, inject 20 units subcutaneously (SQ) every morning. Observation on 03/26/19 at 8:04 A.M. with Licensed Practical Nurse (LPN) #802 of the two front hall medication storage cart revealed Resident #21's Humulin N (long acting insulin) was dated 01/30/19. Interview on 03/26/19 at 8:08 A.M. with LPN #802 confirmed Resident #21's Humulin N was expired and should have been discarded. Review of 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, interview and record review, the facility failed to ensure the results of laboratory testing for Resident #53 were reported promptly to the ordering physician. This affected one of two residents reviewed for catheters. Findings include: Review of the record of Resident #53 revealed he was admitted to the facility on [DATE] with diagnoses including diabetes, cystitis (urinary tract infection), hematuria (blood in the urine) and paraplegia. The resident had a history of bladder and urinary tract infections. Review of his most recent quarterly Minimum Data Set assessment dated [DATE] revealed he was alert, oriented and cognitively intact. Review of a nursing note dated 03/19/19 at 2:30 P.M. revealed Resident #53 told staff he had a bladder infection, stating he had one in the past and knew how it felt. The note indicated the resident catheterized (insertion of a tube into the bladder to drain the urine from the bladder) himself and denied pain or bleeding, but did state there was puss when he…

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 #36's and Resident #44's medical records contained complete and accurate documentation. This affected one (Resident #36) of five residents reviewed for accidents and one (Resident #44) of two residents reviewed for hospitalizations. Findings include: 1. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, hyperlipidemia and urinary tract infection. Review of Resident #36's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of Resident #36's progress note dated 03/13/19 at 5:51 P.M. indicated the resident was transported to an appointment with an escort at the hospital. The State Tested Nursing Assistant (STNA) escorted the resident, notified and updated the staff that the hospital staff escorted the resident to have labs drawn and let the resident leave without the nursing…

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.