Majestic Care Of Cedar Village.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to ensure medication was available and administered according to physicians' orders. This affected one resident (#3) of four residents reviewed for medication administration. The facility census was 142. Findings include: Review of the medical record for Resident #3 revealed an admission on [DATE] with diagnoses including but not limited to irritable bowel syndrome, hypothyroidism, chronic kidney disease and chronic congestive heart failure. Review of the plan of care for Resident #3 dated 07/19/24 revealed resident has potential nutritional risk related to congestive heart failure, congestive obstructive pulmonary disease, hypothyroidism, anemia and abnormal labs. Interventions include laboratory tests as ordered, medications as ordered, registered dietician to evaluate and make diet recommendations as needed. Review of the physician orders for Resident #3 revealed an order dated folic acid, vitamin B6, vitamin B12, 4-50-2…

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.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 133 residents who received meals in the facility. The facility identified four residents (#8, #40, #60 and #122) as receiving no food from the kitchen. The facility census was 137. Findings include: During an observation of the kitchen on 08/15/24, a large swarm of small flying insects were observed around two boxes of exposed potatoes stored in the open, under a window and another directly adjacent in the vicinity of the ice machine. Interview on 08/15/24 at 9:25 A.M. with the Director of Nutritional and Food Services #600 confirmed the presence of the flying insects and stated the potatoes should not be stored in this manner. This deficiency represents non-compliance investigated under Complaint Number OH00156079.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure medication error rates were less than 5% when they administered incorrect medications for Resident #30 and Resident #75 and failed to administer a medication for Resident #75. This affected two Residents (#30 and #75) of three Residents reviewed for medication administration. There was three errors out of 26 opportunities for a medication error of 11.5%. The facility census was 132. Findings include: 1. Record review of Resident #30 revealed an admission date of 07/23/18 with pertinent diagnoses of: hypertensive heart disease, gastrointestinal hemorrhage, left ventricular failure, unspecified vitamin deficiency, and unspecified nutritional deficiency. Review of a Physicians Order dated 04/08/24 Calcium Carbonate Vitamin D-Mineral Oral Tablet 600-400 milligrams (mgs)-unit (Calcium Carbonate-Vitamin D with Minerals). Give one tablet by mouth two times a day for supplement. Observation of a medication administration pass on 04/10/24 at 8:25 A.M. revealed Registered Nurse (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, record review and interview, the facility failed to maintain a clean, sanitary kitchen area, failed to properly store food, failed to maintain an effective pest control program and failed to maintain a current food service license. This affected all residents in the facility except three (Residents #26, #81, #236) who did not receive food from the kitchen. The facility census was 136. Findings include: 1 Review of the facility's food service license on 03/25/24 at 8:23 A.M. revealed it had expired on 03/01/24. During an interview on 03/27/23 at 4:10 P.M., a representative from the local health department verified the facility failed to renew their food service license. 2. During observations on 03/25/24 at 8:23 A.M., there was food splatter and debris up and down the kitchen wall at the hand wash sink. There was debris caked on the plate warmer and down the front of the ice machine. Walk in refrigerator #01 contained a large metal pan of scrambled eggs with no label, eight large metal cookie sheets with cookies and no label, two large cookie sheets with four…

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 policy review, the facility failed to ensure resident care conferences were held quarterly. This affected three (Residents #109, #107, and #12) of three residents reviewed for care planning. The census was 136. Findings include: 1. Review of the medical record revealed Resident #109 was admitted on [DATE]. Review of the care plans for Resident #109 revealed no documentation a care plan conference was held between 01/11/23 and 12/27/23. During an interview on 03/27/24 at 3:01 P.M., Resident #109 stated he could not remember when his last care conference was held, but it had been a while back. 2. Record review revealed Resident #107 was admitted on [DATE]. Review of the care plans for Resident #107 revealed no documentation a care plan conference had been held between 09/16/22 and 03/28/24. During an interview on 03/28/24 at 8:56 A.M., Resident #107 stated she has never attended a care plan conference since her admission to the facility. 3. Record review revealed Resident #12…

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 policy review, the facility failed to initiate a requested room change for a resident. This affected one (Resident #18) of one resident reviewed for room change. The facility census was 136. Findings include: Record review revealed Resident #18 was admitted on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other specified depressive episodes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/05/24, revealed the resident was cognitively impaired, had no functional limitations and was dependent for toileting, bathing, transfers and dressing. During an interview on 03/25/24 at 12:52 P.M., Resident #18 stated her roommate screams all night. She had asked for a room change but has not received one. She stated a month ago she reported a complaint about her roommate being in her bed when she came back to the room. During an observation on…

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

Based on observation and interview, the facility failed ensure resident equipment was in good repair and failed to keep the dining room clean. This affected six (Residents #29, #62, #67, #94 #107, and #121) residents. The facility census was 136. Findings include: 1. During an observation on 03/26/24 at 1:01 P.M. the arm rests and seat on the over the toilet chair in Resident # 29's were torn in several places. Some of the tears were covered with tape. The chair arms had several ripped and torn areas that were not covered, and the taped areas had rough edges on them. During an interview at the time of the observation, State Tested Nursing Assistant (STNA) #18 confirmed the above findings. 2. During an observation on 03/25/24 at 11:28 A.M., Resident #62's mattress was too small for the bed. There was a two foot gap between he top of the bed frame and the mattress at the head of the bed. Resident #62 stated at the time of the observation he has asked for a new mattress on several occasions and each time is told it is on order. During interview on 03/26/24 at 12:24 P.M. with Licensed…

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 hospital records, review of a Self-Reported Incident (SRI), staff interview, and policy review, the facility failed to accurately report an injury of unknown origin to the state agency. This affected one (Resident #337) of one resident reviewed for injuries of unknown origin. The facility census was 136. Findings include: Review of the closed medical record for Resident #337 revealed he was admitted to the facility on [DATE] and was discharged on 03/18/24. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, other hyperlipidemia, hypertensive heart disease with heart failure, spinal stenosis, bipolar disorder, type two diabetes mellitus without complications, anxiety disorder, chronic respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery without angina pectoris, and depression. Review of the five-day Minimum Data Set (MDS) assessment, dated 03/01/24, revealed this resident had moderately impaired cognition. This resident 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 record review, interview and policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (Resident #337) of one resident reviewed for injuries of unknown origin. The facility census was 136. Findings include: Review of the closed medical record for Resident #337 revealed he was admitted to the facility on [DATE] and was discharged on 03/18/24. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, other hyperlipidemia, hypertensive heart disease with heart failure, spinal stenosis, bipolar disorder, type two diabetes mellitus without complications, anxiety disorder, chronic respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery without angina pectoris, and depression. Review of the five-day Minimum Data Set (MDS) assessment, dated 03/01/24, revealed this resident had moderately impaired cognition. This resident was assessed to require supervision for eating and oral hygiene, maximal…

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 policy review the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASARR) was completed for residents. This affected two (Residents #55 and #124) of three residents reviewed for PASARR status. The facility census was 136. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 03/01/22. Diagnoses included major depressive disorder, single episode, unspecified and bipolar ii disorder. Review of the PASARR assessments revealed an assessment was completed on 03/01/22 for a less than 30 day stay and another assessments was completed on 05/23/23 for a stay more than 30 days. During an interview on 03/28/24 at 1:29 P.M., Social Service Director #717 confirmed the PASARR was not completed timely once Resident #55 stayed past 30 days. 2. Review of the medical record for Resident #124 revealed she was admitted to the facility on [DATE]. Diagnoses included unspecified dementia unspecified severity with other…

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 faciltiy failed to serve residents their preferred food items. This affected three (Residents #38, #70, and #72) of three residents reviewed for meal preferences. Ths facility census was 136. Findings include: Review of Resident Council Meeting Minutes revealed on 12/28/23 residents complained about not getting the items listed on their meal tickets. On 02/23/24 residents again complianed the meals did not match what is on the meal tickets that they filled out. During an observation on 03/27/24 at 9:12 A.M., Resident #38's meal ticket had her food choices as grapes, orange slices, skim milk, eggs with cheese on them and corn flakes cereal. Observation of Resident #28's breakfast tray revealed she received received strawberries, two percent milk, eggs without cheese and no cereal. During an observation on 03/27/24 at 9:20 A.M., Resident #70's meal ticked had his food choices as scrambled eggs and orange juice. He received fried eggs and cranberry juice. During an observaiton on 03/27/24 at 9:32 A.M., Resident #72's meal ticket…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility policy and procedure review, and staff interview, the facility failed to ensure medications were administered without significant errors. This affected one (Resident #51) of three residents reviewed for medications. The facility census was 139. Findings include: Review of Resident #51's medical record revealed an admission date of 08/03/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, respiratory failure, hypertensive heart disease, and type two diabetes mellitus without complications. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact. Review of a Medication Error Report dated 09/09/23 revealed Resident #51 received the following medications in error, that were prescribed for Resident #141: Metoprolol…

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, staff interviews and policy reviews, the facility failed ensure to ensure medications were disposed of, if out dated and not in circulation for resident use. This had the potential to affect 143 of 143 residents who resident in the facility. The census was 143. Findings include: Observations on [DATE] at 2:13 P.M. of the [NAME] unit medication room with Registered Nurse (RN) #177 revealed an open multi-dose vial of tuberculin purified protein testing solution with the expiration date of 02/22 with no date when opened. Interview with RN #177, at the time of the observation, revealed the multi-dose vial of tuberculin purified protein testing solution should have a date when opened and was good for 28 days after opened. Observations on [DATE] at 2:45 P.M. of Peachtree unit medication room revealed an open multi-dose vial of Lidocaine 1% injectable 200 milligram (mg)/20 milliliter (ml) with no date when opened, two boxes of over the counter Simethacone 125 mg chewable tabs with an expiration…

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

Based on observations, resident and staff interviews, and review of the housekeeping procedure manual, the facility failed to maintain residents' rooms in a clean and sanitary manner. This affected nine residents (#25, #39, #40, #60, #79, #81, #106, #136, and #141) out of 26 residents residing in the Redbud building. The facility census was 143. Findings include: Observation on 06/07/21 at 2:16 P.M., revealed Resident #106 floors not swept and mopped. Paper, Kleenex, and dirt on dark colored carpet floors. Observation on 06/08/21 at 10:39 A.M., revealed Resident #40 room had balled up tissues around her bed with noticeable crumbs and food particles on the dark carpet. Observation on 06/09/21 at 2:30 P.M., revealed Resident #141's carpet consisted of food particles scattered on the floor. Interview on 06/09/21 at 2:30 P.M., with Resident #141 reported he has not seen housekeeping in days. Observation on 06/09/21 at 2:35 P.M., revealed Resident #81 had sugar packets, napkins, and Kleenexes balled up on the floor under the bed. There were paper and crumbs scattered on the dark colored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to provide baths/showers to residents depended on staff for care. This affected four (#34, #25, #106, and #141) of six residents sampled for activity of daily living. The facility census was 143 residents. Findings include: 1. Review of Resident #34 medical record revealed an admission date 03/25/21, with diagnoses including muscle spasm, peripheral vertigo of left ear, phlebitis and thrombophlebitis of other deep vessels of lower extremity, weakness, urinary tract infection, spinal stenosis of cervical region, hypertension, gastro-esophageal reflux disease, pain, anemia, insomnia, anxiety disorder, depressive disorder, osteoporosis, osteoarthritis, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact with no rejection of care and required total one person assist with bathing. Review of the Activity of Daily Living (ADL) plan of…

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

Based on observations, staff interviews, and review of the facility's policy, the facility failed to maintain the resident dining rooms in a clean and sanitary manner. This affected 15 residents (#14, #15, #25, #27, #39, #40, #48, #60, #79, #81, #103, #106, #110, #116, and #136) residing in the Redbud building and the potential to affect any resident that could eat in the Peach Tree dining room. The facility census was 143. Findings include: Observation on 06/07/21 at 10:51 A.M., revealed the Red [NAME] Terrace Dining Room floors had red stains on the floors, food particles scattered and spread throughout the dining room, and the base of tables were covered with dirt and crumbs. Observation on 06/09/21 at 3:15 P.M., revealed the Red [NAME] Terrace Dining Room contained dirt, debris and food crumbs on the floor. There were 11 tables with base and all of the base were covered with dirt, debris and food crumbs. Interview on 06/09/21 at 3:20 P.M., with State Tested Nursing Assistant (STNA) #150 revealed she has not seen housing keeping at all today. STNA #150 was scheduled for 7:00 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility failed to eradicate flying insects (gnats) in resident care areas. This affected 24 residents who reside on Apple unit on the third floor and 18 residents who reside on the [NAME] unit on the second floor. The facility census 143. Findings included: Observations on 06/08/21 at approximately 4:00 P.M., a gnat was observed and killed in the first floor board room. Observation on 06/09/21 at 8:55 A.M., a gnat was observed flying down the hall outside the [NAME] soiled utility room and confirmed by Licensed Practical Nurse (LPN) #147. Observation on 06/09/21 at 2:59 P.M., a gnat was seen on the third floor Apple unit flying near nursing station and confirmed by Registered Nurse #129. Review of the facility pest control log revealed Pest control dated 09/04/20 revealed rooms 241, 262, 263, 236 233, and 232 were treated for small flies. On 09/17/20, rooms [ROOM NUMBERS] were treated for small flies. On 09/29/20, room [ROOM NUMBER] was treated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to ensure a resident's Foley catheter bag was covered for privacy. This affected one (#34) of one sampled resident, of six residents with indwelling Foley catheters. The facility census was 143 residents. Findings included: Review of Resident #34's medical record revealed an admission date of 03/25/21, with diagnoses that included muscle spasm, weakness, history of urinary tract infection, spinal stenosis of cervical region and neurogenic bladder. The admission Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no rejection of care and indwelling Foley catheter. The plan of care dated 04/06/2021 revealed the resident had an indwelling urinary catheter related to neurogenic bladder. Observations on 06/07/21 at 12:23 P.M., in the Apple Grove dining room revealed Resident #34 seated in a wheelchair with an uncovered Foley catheter drainage bag attached to the wheelchair…

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 staff interviews, the facility failed to provide eyeglasses daily to a resident dependent on staff for all activities of daily living. This affected one (#25) of one resident sampled for vision. The census was 143. Findings include: Review of medical record for Resident #25 revealed an admission date of 07/27/18 with diagnoses included cerebrovascular disease, dementia, and cognitive communication deficit. Review of quarterly minimum data set (MDS) assessment, dated 03/23/21, revealed Resident #25 was assessed being severely cognitively impaired. Resident #25 have adequate vision with glasses and is dependent for all activity of daily living. Review nursing notes revealed no concerns with refusing to wear eyeglasses. Observation on 06/07/21 at 2:32 P.M., 06/09/21 at 12:01 P.M., revealed Resident #25 was sitting in room trying to watch television. Observations on 06/14/21 at 11:50 A.M., revealed Resident #25 was not wearing eyeglasses. Interview on 06/14/21 at 11:55 A.M., with State Tested Nursing Aide (STNA) #87, the STNA assigned to Resident…

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

Based on observations, resident record reviews, and staff interviews, the facility failed to administer medications per physician orders. A total of 25 opportunities with two errors which resulted in a 8 percent medication error rate. This affected one (#114) of five residents observed during medication administration. Facility census was 143 residents. Findings include: Observations of Medication Administration on 06/09/21 at 8:19 A.M. with Licensed Practical Nurse (LPN) #147 revealed Resident #114 was to receive Timoptic 0.5% ophthalmic solution one drop in right eye and Systane Balance (propylene glycol) 0.6 percent drops one drop in the left eye for the treatment of glaucoma to prevent a rise in intraocular pressure. LPN #147 place one drop of Timoptic 0.5% ophthalmic solution in Resident #114's left eye and started to put one drop of lantanoprost 0.005 percent drops into Resident #114's right eye when the nurse was stopped for clarification. Record review revealed Resident #114 had a physician order dated 05/11/21 for Timoptic 0.5% ophthalmic solution one drop in right eye 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 observations, resident record reviews, and staff interviews, the facility failed to correctly transcribe physician admission orders which resulted in residents not getting the prescribed medication. This affected one (#114) of five residents observed during medication administration. Facility census was 143 residents. Findings include: Observations of Medication Administration on 06/09/21 at 8:19 A.M. with Licensed Practical Nurse (LPN) #147 revealed Resident #114 was to receive Timoptic 0.5% ophthalmic solution one drop in right eye and Systane Balance (propylene glycol) 0.6 percent drops one drop in the left eye for the treatment of glaucoma to prevent a rise in intraocular pressure. LPN #147 place one drop of Timoptic 0.5% ophthalmic solution in Resident #114's left eye and started to put one drop of lantanoprost 0.005 percent drops into Resident #114's right eye when the nurse was stopped for clarification. Record review revealed Resident #114 had a physician order dated 05/11/21 for Timoptic 0.5%…

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 interview, staff interview, and facility policy review, the facility failed to ensure a resident was treated with respect when a staff member made an inappropriate comment to a resident. This affected one Resident (#130) of one reveiwed for respect. The facility census was 142. Findings include: Medical record review for Resident #274 revealed an admission of 01/06/20 with diagnoses including cerebrovascular attack (stroke) with paralysis to the left side. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. Interview with Resident #274 on 01/27/20 at 11:45 A.M. revealed a State Tested Nursing Aide (STNA) #140 told him a few days ago in the dining room in front of the other residents, when he complained of pain in his leg, the STNA told him they would have to cut his left off. He revealed he though the commend was rude. Interview with STNA #140 on 01/27/20 at 4:46 P.M. denied she said we will have to cut your…

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.