Legends Care Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, interview with staff, and review of facility policy, the facility failed to maintain and medication error rate of less than five percent (%). Nine medications were given in error out of 25 opportunities for error, to equal an error rate of 36%. This affected one resident (Resident #18) out of four observed for medication administration.Findings Include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included lupus, acute respiratory failure, moderate protein-calorie malnutrition, gastrostomy status, and dysphagia.Review of the January 2026 physician's orders revealed Resident #18 had orders due at 9:00 A.M. for acidophilus 500 million units daily, Bactrim DS 800/160 milligrams (mg) daily, prednisone 10 mg daily, Protonix 40 mg Delayed Release (DR) daily, zinc sulfate 220 mg daily, Mucinex 600 mg twice daily, senna plus 8.6/50 mg twice daily, baclofen 10 mg three times daily, and oxycodone 10 mg three times…

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 medical record and interview with staff, the facility failed to ensure radiologic study recommendations were scheduled and addressed in a timely manner for Resident #58. This affected one resident (Resident #58) of three reviewed for a change in condition.Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE].Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition.Review of the Progress Note dated 09/15/25 at 4:18 P.M. revealed Resident #58 was resting in bed. The resident complained of being more tired than usual. The resident ' s family called into the facility stating he must go to the hospital.…

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 the fingernails on Resident #205's bilateral hands were assessed and treated timely. This finding affected one (Resident #205) of one resident reviewed for activities of daily living (ADL). Findings include: Review of Resident #205's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, displaced comminuted fracture of the shaft of the right humerus and lack of coordination. Review of Resident #205's ADL care plan dated 05/15/25 revealed to check the resident's nail length. Trim and clean on bath days and report any changes to the nurse. Review of Resident #205's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and the resident was dependent for toileting, showering/bathing as well as partial/moderate assistance for personal hygiene. Review of Resident #205's Weekly Skin Assessment form dated 05/19/25 did not address…

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, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected one resident (Resident #15) of one resident reviewed for behavioral and emotional care. The facility census was 49. Findings include: Review if the medical record for Resident #15 revealed an initial admission date of 03/20/25 and a re-entry date of 05/20/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, primary hypertension, chronic stage three kidney disease, anxiety disorder, heart failure, cognitive communication deficit, depression, muscle wasting and atrophy, and post-traumatic stress disorder (PTSD). Review of the admission minimum data set (MDS) 3.0 assessment completed on 03/27/25 revealed Resident #15 had moderately impaired cognition and no noted behaviors. Further review of the MDS revealed Resident #15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure medications were administered as ordered. A total of 31 medications were administered with two errors for a medication error rate of 6.45%. This finding affected two (Residents #19 and #40) of three residents observed for medication administration. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, morbid obesity and chronic obstructive pulmonary disease. Review of Resident #19's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment. Review of Resident #19's physician orders revealed an order dated 04/13/24 to administer Humalog via a KwikPen sq (subcutaneous) and inject as per sliding scale. Using a Humalog KwikPen, inject four units for a sliding scale of 200 to 250; six units for a sliding scale of 251 to 300; eight units for a sliding scale of 301 to 350; 10 units for a sliding scale 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 medical record review, hospital records, facility policy review and staff interviews, the facility to complete a timely investigation and self-reported incident following an injury of unknown origin for one resident (Resident #243). This had the potential to affect all 51 residents residing at the facility. Findings include: Review of the medical record for Resident #243 revealed an admission date of 02/11/25. Diagnoses included but were not limited to type II diabetes mellitus with hyperglycemia, Alzheimer's dementia, unspecified disorder of muscle, Trisomy 21, severe intellectual disabilities, adjustment disorder, dysphagia, localization-related idiopathic epilepsy and epileptic syndromes with seizures, tremors, and hearing loss. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #243 had a severe cognitive impairment. Resident #243 was noted to rarely be understood. Resident #243 was noted to use a wheelchair, required moderate assistance for ADLs. 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 staff interview, record review, and facility policy review, the facility failed to notified the resident's family/responsible party and the physician timely upon the death of two residents (#60 and #61). This affected two residents (#60 and #61) of three residents reviewed for death. The facility census was 53. Findings include: 1. Review of the closed medical record for Resident #60 revealed an admission date of 06/15/21. Diagnoses included chronic obstructive pulmonary disease (COPD), esophageal obstruction, and cerebrovascular disease. Review of Resident #60's physician's orders dated 06/15/21 revealed the resident was a Full Code (advance directives). The physician orders dated 04/30/24 revealed an order for Hospice Provider #333 to provide services for Resident #60 for a diagnosis of COPD with lower obstruction. Review of the progress notes for Resident #60 dated 03/01/25 at 8:30 A.M. and completed by Registered Nurse (RN) #301 revealed Resident #60 was absent of vital signs at 8:30 A.M. This was verified by RN #301 and nurse on duty (Licensed Practical Nurse (LPN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, observation, medical record review, review of the Self-Reported Incident (SRI) and investigation, and review of the facility policy, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse. This affected two (Residents #15 and #38) of three residents reviewed for abuse. The facility census was 53. Findings include: Record review for Resident #15 revealed an admission date of 07/01/21. Diagnoses included Alzheimer's disease, anxiety disorder, and mood disorder due to known physiological condition with depressive features. Review of the modification of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. Resident #15 had little interest or pleasure in doing things. The presence of wandering also occurred one to three days. Review of the progress note dated 02/04/25 at 8:58 P.M. completed by the Director of Nursing (DON) revealed Resident #15 was seen pushing another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure staff were competent and compliant with implementing cardiopulmonary resuscitation per the physician orders and failed to ensure the resident's time of death was called by the physician for accuracy. This affected two residents (#60 and #61) of three residents reviewed for Advanced Directives. The facility census was 53. Findings include: 1. Review of the closed medical record for Resident #60 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), esophageal obstruction, and cerebrovascular disease. Review of Resident #60's physician's orders dated [DATE] revealed the resident was a Full Code (advance directives). The physician orders dated [DATE] revealed an order for Hospice Provider #333 to provide services for Resident #60 for a diagnosis of COPD with lower obstruction. Review of the modification of the quarterly Minimum Data Set (MDS)…

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, review of the medical record, interview with staff and review of the facility policy the facility failed to ensure Resident #16, who was dependent on staff for activities of daily living (ADL), was shaved, had his fingernails trimmed and was showered per his preference. This affected one resident (Resident #16) of three residents reviewed for showers. The facility census was 50. Findings included: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included left side hemiplegia, cerebral infarction, anxiety disorder, depression and paralytic gait. Review of the plan of care dated 02/27/24 revealed Resident #16 had a self-care deficit related to weakness. Interventions included he needed one assist with grooming and hygiene. Further review of the plan of care dated 03/01/24 revealed Resident #16 had an ADL self-care performance deficit related to decreased mobility function activity intolerance. Interventions included to check his nail…

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 medical record and interview with staff the facility failed to ensure medication was obtained from the pharmacy after admission in a timely manner for Resident #48. This affected one resident ( Resident #48) of three residents reviewed for medications. The facility census was 50. Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included low pain, osteomyelitis, diabetes, insomnia, anxiety disorder, arthropathy, depression, polyneuropathy, dementia, lumbar vertebrae fracture, and benign prostatic hyperplasia. Review of the physician's orders revealed Resident #48 had an order for zolpidem tartrate (sedative/hypnotic) 5 milligrams at bedtime for insomnia dated 06/14/24. Review of the Five-Day Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #48 had intact cognition. Review of the Electronic Medication Administration Record (EMAR) progress note dated 06/16/24 at 3:33 A.M. revealed the facility was waiting 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 observation, review of the medical record, interview with staff, and review of the facility policy the facility failed to maintain a medication error rate of less than five percent. Two medication errors occurred within 31 opportunities for error resulting in a medication error rate of 6.5 percent. This affected one resident (Resident #1) of three observed for medication administration. The facility census was 50. Findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included asthma, depression, arthritis, falls, prediabetes, shortness of breath, palpitations and anxiety disorder. Review of the July 2024 medication administration record revealed Resident #1 had an order for duloxetine 30 milligrams (mg) and to administer 60 mg in the morning for depression. She did not have an order for Zoloft 50 mg. Observation of medication administration on 07/09/24 at 7:30 A.M. revealed Resident #1 had a card of duloxetine with the order for two…

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 staff and review of the facility policy the facility failed to ensure staff performed hand hygiene during medication administration. This affected one resident ( Resident #2) of three observed for medication administration. The facility census was 50. Findings included: Observation on 07/09/24 at 7:37 A.M. revealed Licensed Practical Nurse (LPN ) #250 administered medications, eye drops (resident self-administered), inhaler, nasal spray to Resident #1, came out of the residents room into the hallway to the medication cart and put the items away in the medication cart and set up medications for Resident #2 then went back into the room, administered the medication to Resident #2, went into the bathroom and got a pair of gloves and put them on to administer her insulin in her left arm. She administered the insulin, left the room, and threw her gloves away in the trash can on the medication cart in the hallway. She never washed her hands after administering medication to Resident #1, prior to administering medication to Resident #2, or after removing…

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, review of pest control invoices, review of pest control logs, interview with staff, and review of the facility policy the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 51 residents who received meals from the kitchen. Two residents (#31 and #33) were identified by the facility as receiving nothing by mouth. The facility census was 53. Findings include: 1. Observation of the kitchen on 06/13/24 at 9:00 A.M. with [NAME] #122 revealed the stainless-steel table by the dishwasher, which had the chemical on it, was dirty with food debris and dirt, the stainless-steel table, by the steam table revealed the bottom shelf was dirty with food debris and dirt buildup, the stainless-steel table the coffee maker was on, had dirt on the top and the shelf underneath had coffee spilled, food debris and dirt on it. There was a three-drawer plastic container which was dirty with coffee and a pink substance spilled down the front of it. The flour and sugar plastic containers were dirty with a buildup of dirt on the outside 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 review of the medical record, review of the facility's Self-Reported Incident (SRI), interview with staff and family, and review of the facility policy the facility failed to ensure Resident #53 was treated with dignity and respect during care by a facility staff member. This affected one resident (#53) of three residents reviewed for dignity and respect. The facility census was 53. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included diabetes, Parkinson's disease, osteoarthritis, dementia, Alzheimer's disease, obstructive sleep apnea, major depressive disorder, attention-deficit hyperactivity disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had severely impaired cognition and had no behaviors. Review of the progress notes dated 05/27/24 at 8:09 P.M. revealed the Administrator left a message for the daughter of Resident #53 to call her regarding accusations…

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 medical record and interview with staff the facility failed to ensure an ultrasound was scheduled for Resident #53 in a timely manner. This affected one resident (#53) of three residents reviewed for care and services. The facility census was 53. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included diabetes, Parkinson's disease, osteoarthritis, dementia, Alzheimer's disease, obstructive sleep apnea, major depressive disorder, attention-deficit hyperactivity disorder, and hypertension. Review of the Nurse Practitioner's progress note dated 02/26/24 revealed Resident #53 was having left breast pain. The plan was to schedule a mammogram. Review of the mammogram results dated 03/04/24 revealed Resident #53 had a 1.5 centimeter (cm) oval nodule in the right breast at 11 o'clock and a 2.0 cm oval nodule in the left breast at three o'clock. The results were incomplete, and the resident will need additional evaluation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the meal ticket, interview with staff, and review of facility policy the facility failed to ensure Resident #34 received to correct physician's ordered diet. This affected one resident (#34) of three residents reviewed for diet orders. The facility census was 53. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, respiratory failure, diabetes, heart failure, muscle wasting, pulmonary hypertension, dysphagia, aphonia, gastrostomy, pulmonary embolism, and hypertension. Review of the June 2024 physician's orders revealed Resident #34 had an order for a regular diet with thin liquids dated 06/07/24. Review of the list of resident's diets revealed the facility had no residents receiving thickened liquids. Review of the diet ticket dated 06/17/24 revealed Resident #34 was to have nectar thick liquids. Observation of meal service on 06/17/24 at 11:15 A.M. revealed 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 observation, interview and record review the facility failed to ensure resident grievances were addressed regarding call light response times. This had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Based on observation, interview and record review the facility failed to ensure resident grievances were addressed regarding call light response times. This had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Review of resident council minutes for February 2024 revealed resident complaints regarding long call light response times and aides at the nurse's station while call lights not being answered. Review of Resident Council Minutes for March 2024 revealed call light response was still too long and aides were still on their phones from time to time. Interview on 05/01/24 at 9:39 A.M. with Resident #39 revealed call light response time was usually 30 to 45 minutes. Resident #39 indicated he had reported this concern to the Administrator and had not…

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

Based on observation, interview and record review the facility failed to ensure adequate staffing to meet resident needs. This affected Residents #39, #43, #5, #2, #52, and had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Interview on 05/01/24 at 9:39 A.M. with Resident #39 revealed it usually took about 30 to 45 minutes for staff to respond to his call light. Interview on 05/01/24 at 10:04 A.M. with Resident #43 revealed it took staff a long time to respond to her call light, especially during the evening hours. Interview on 05/01/24 at 10:19 A.M. with State Tested Nursing Assistant (STNA) #255 revealed there were occasions when there were only two to three aides for entire building and due to lack of staff some residents who required two person assistance out of bed were not gotten up. Interview on 05/01/24 at 10:50 A.M. with STNA #237 revealed from 7:00 A.M. to 8:00 A.M. she was the only STNA present for the 400, 500 and 600 halls which included 24 residents because of a call off. STNA #237 indicated this occurred…

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 personnel file review the facility failed to ensure staff concerns related to staff conduct were addressed. This had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Interview on 05/02/24 at 5:35 A.M. with Licensed Practical Nurse (LPN) #202 revealed she informed the Administrator of concerns related to LPN #275 taking extended and frequent breaks and sleeping while on duty. LPN #202 stated on the evening of 04/20/24, LPN #275 was outside in the facility parking lot for three to four hours during her shift. LPN #202 stated she called the Administrator on 04/20/24 sometime after 2:30 A.M. to inform her Resident #61 had fallen and was being transported to the hospital. LPN #202 also informed the Administrator that LPN #275 was not present in the facility during the time Resident #61 had fallen; she was in the parking lot. LPN #202 stated the Administrator had been informed of LPN #275 not being present during her shifts prior to 04/20/24 and nothing had been done. Telephone interview on 05/02/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review the facility failed to ensure residents/resident representative participated in care planning. This affected two (#26 and #37) of three residents reviewed for care planning process. Findings include: 1. Review of Resident #26's medical records revealed an admission date of 02/02/23. Diagnoses included difficulty walking, amputation and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had impaired cognition and required moderate assistance with toileting, bathing and personal hygiene. Review of a care conference assessment for Resident #26 revealed a care conference was held on 10/12/23. There were no other care conference assessments or any other evidence of care conferences having been completed in the medical record. Review of the care plan dated 03/19/24 revealed Resident #26 required two staff assist with toileting and to encourage the resident to participate as much as able with activities of daily…

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, review of a self reported incident, and review of facility policy, the facility failed to ensure verbal abuse did not occur. This affected one (#5) of three residents reviewed for abuse. Facility census was 58. Findings include: Review of Resident #5's medical records revealed an admission date of 04/06/24. Diagnoses included morbid obesity and muscle weakness. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and required moderate assistance with toileting, bathing, personal hygiene and bed mobility. Review of the progress note dated 04/28/24 revealed Resident #5 called Licensed Practical Nurse (LPN) #229 into her room to report an aide calling her an inappropriate name. Resident #5 stated she had used her call light to request ice and when the aide came into her room Resident #5 also asked for a soda. Resident #5 stated the aide rolled her eyes and sighed. Resident #5 stated she was not trying to cause any problems and stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to report an injury of unknown origin to the State Agency as required. This affected one (Resident #37) of three residents reviewed for abuse. Findings include: Review of Resident #37's medical records revealed an admission date of 11/15/21. Diagnoses included Alzheimer's disease, dementia and altered mental status. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #37 had impaired cognition, and required moderate assistance with toileting, bathing and personal hygiene. Review of the care plan dated 05/02/23 revealed Resident #37 was at risk for skin breakdown. Interventions included observing skin for redness and open areas and notify the nurse. Review of the shower sheet dated 04/25/24 revealed bruising to the upper arms. There was no description of the bruising. Telephone interview on 05/07/24 at 10:38 A.M. with Resident #37's daughter revealed she had concerns related to bruising on Resident #37's arms. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of a self reported incident, and review of the facility abuse policy and procedure, the facility failed to thoroughly investigate an allegation of verbal abuse and an injury of unknown origin. This affected two (#5, #37) of three residents reviewed for abuse. Facility census was 58. Findings include: 1. Review of Resident #5's medical records revealed an admission date of 04/06/24. Diagnoses included morbid obesity and muscle weakness. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and required moderate assistance with toileting, bathing, personal hygiene and bed mobility. Review of the progress note dated 04/28/24 revealed Resident #5 called Licensed Practical Nurse (LPN) #229 into her room to report an aide calling her an inappropriate name. Resident #5 stated she had used her call light to request ice and when the aide came into her room Resident #5 also asked for a soda. Resident #5 stated the aide rolled her eyes…

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 care plan were implemented as written. This affected two (#29 and #37) of four residents reviewed for skin impairment. The facility census was 58. Findings include: 1. Review of Resident #29's medical records revealed an admission date of 01/12/24. Diagnoses included dementia, altered mental status and difficulty walking. Review of Resident #29's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was rarely understood, was dependent with toileting, bathing and personal hygiene, and incontinent of bowel and bladder. Review of the care plan dated 01/18/24 revealed Resident #29 was at risk for skin breakdown. Interventions included observing skin for redness and open areas and notify the nurse. Telephone interview on 05/08/24 at 10:04 A.M. with Resident #29's daughter revealed she had visited Resident #29 on 05/05/24 and had observed blood on the resident's pillowcase. Resident #29's daughter noted Resident #29 had a…

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

Based on observation, interview, and personnel file review the facility failed to ensure medications were stored in locked compartments, labeled, and only authorized personnel had access. This affected one (#22) of three residents who were randomly observed for medications being left unattended. Facility census was 58. Findings include: Observation on 05/06/24 at 10:20 A.M. revealed Resident #22 was sleeping in bed with a medication cup on his bedside table that contained approximately 8-10 pills. Interview with Registered Nurse (RN) #246 on 05/06/24 at time of observation confirmed the medication at Resident #22's bedside. RN #246 stated he thought Resident #22 was going to take the medications once he woke up. RN #246 stated he should have remained in Resident #22's room while medications were consumed. Review of RN #446's personnel file revealed a written warning dated 05/06/24 indicating RN #246 had left medication at a resident's bedside.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accurate documentation on a Medication Administration Record (MAR). This affected one (#29) of four residents reviewed for documentation. The facility census was 58. Findings include: Review of Resident #29's medical records revealed an admission date of 01/12/24. Diagnoses included dementia, altered mental status and difficulty walking. Review of Resident #29's Minimum Data Set assessment dated [DATE] revealed Resident #29 was rarely understood and was dependent on staff for toileting, bathing and personal hygiene. Review of the MAR on 05/08/24 at 11:25 A.M., for April 2024 revealed Registered Nurse (RN) #246 documented medications as being administered on 04/24/24, 04/27/24 and 04/28/24. Review of MAR for May 2024 revealed RN #246 documented medications as being administered on 05/02/24. Review of the April and May 2024 MARs and interview on 05/08/24 at 1:05 P.M. with the Administrator confirmed RN #246 had signed off the medications 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 review of the medical record, interview with the staff, interview with the resident and review of the facility policy the facility failed to ensure an allegation of mistreatment was reported to the Ohio Department of Health (ODH). This affected one resident (Resident #49) of six reviewed for abuse. The facility census was 57. Findings included: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included disorder of the muscles, muscle wasting and atrophy, cirrhosis of the live due to alcohol, severe protein-calorie malnutrition, epilepsy, transient ischemic attack, vitamin D deficiency, anemia, cholelithiasis, liver disease, history of falls, and altered mental status. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #49 had intact cognition. She received partial to moderate assistance for rolling side to side in bed. She was also frequently incontinent of bowel and bladder function. Review of the progress notes from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, interview with the staff, interview with the resident and review of the facility policy the facility failed to thoroughly investigate an allegation of mistreatment. This affected one resident (Resident #49) of six reviewed for abuse. The facility census was 57. Findings included: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included disorder of the muscles, muscle wasting and atrophy, cirrhosis of the live due to alcohol, severe protein-calorie malnutrition, epilepsy, transient ischemic attack, vitamin D deficiency, anemia, cholelithiasis, liver disease, history of falls, and altered mental status. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #49 had intact cognition. She received partial to moderate assistance for rolling side to side in bed. She was also frequently incontinent of bowel and bladder function. Review of the progress notes from 03/22/34 to 03/31/24 revealed 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 review of the medical record, review of the hospital records and interview with staff the facility failed to ensure Resident #60 was not unnecessarily transferred to a hospital. This affected one resident (Resident #60) of three reviewed for hospitalization. The facility census was 57. Finding included: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses of encephalopathy, diabetes, acute kidney disease, protein-calorie malnutrition, Respiratory failure, chronic obstructive pulmonary disease, disruption of external operation wound, anemia, schizophrenia, ileostomy, hyperlipidemia, and hypertension. Resident #60 was sent to the hospital emergency room (ER) on 03/22/24 but not admitted to the hospital. He was later discharged to another facility on 03/25/24. Review of the Medicare Five-Day assessment dated [DATE] revealed Resident #60 had intact cognition. He had an ostomy and was frequently incontinent of bladder and bowel. He had a surgical wound. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of the ostomy company invoice and interview with staff the facility failed to ensure ostomy and drainage tube care was provided to Resident #60. This affected one resident (Resident #60)of three reviewed for ostomy care. The facility census was 57. Findings included: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses of encephalopathy, diabetes, acute kidney disease, protein-calorie malnutrition, respiratory failure, chronic obstructive pulmonary disease, disruption of external operation wound, anemia, schizophrenia, ileostomy, hyperlipidemia, and hypertension. He was discharged to another facility on 03/25/24. Review of the physician's orders from 03/19/24 to 03/24/24 revealed no orders for ostomy or drainage tube care. Review of the Medicare Five-Day Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition. He had an ostomy and was frequently incontinent of bladder and bowel. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of the emergency medication kit list, review of the hospice notes and interview with staff the facility failed to ensure an effective pain management program was implemented for Resident #58. This affected one resident (Resident #58) of three reviewed for pain management. The facility census was 57. Findings included: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease ischemic cardiomyopathy, atherosclerotic heart disease, paroxysmal atrial fibrillation, congestive heart failure, biventricular heart disease, anemia, cerebral infarction, cognitive communication deficit, and dementia. He expired on [DATE]. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #58 had moderately impaired cognition and received no pain medications. Review of the physician's orders dated [DATE] revealed Resident #58 had orders for hospice services and hydromorphone (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 medical record and interview with staff the facility did not ensure the application of a negative pressure wound therapy machine was accurately documented in the medical record for Resident #60. This affected one resident (#60) of three residents reviewed for wound care documentation. The facility census was 57. Findings included: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses of encephalopathy, diabetes, acute kidney disease, protein-calorie malnutrition, respiratory failure, chronic obstructive pulmonary disease, disruption of external operation wound, anemia, schizophrenia, ileostomy, hyperlipidemia, and hypertension. He was discharged to another facility on 03/25/24. Review of the hospital discharge orders dated 03/19/24 revealed Resident #60 had an abdominal wound managed with negative pressure wound therapy (wound vac) to be change on Monday, Wednesday, and Friday with specialized foam. Review of the admission assessment dated…

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 written complaints, review of facility investigation, review of staffing schedule and employee timecard punches, and interview, the facility failed to ensure a resident representative complaint was thoroughly investigated related to a staff member being impaired. This affected one resident (#12) of three residents reviewed. The facility census was 57. Findings include: Review of a 11/04/23 complaint investigation revealed Resident #12 approached Licensed Practical Nurse (LPN) #88 at the nurses station and started to report to staff nurses LPN #88 and #95 that the Director of Nursing (DON) had called him on the phone the night before for about two hours. He asked, is she on something? you guys might need to drug test her. When he continued talking, he made statements like: she said how her and my dad had a special relationship he said there have been nights that he didn't sleep the entire night like what am I supposed to think? She was saying some really weird and suggestive things about my…

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, review of the medical record and interviews with staff the facility failed to ensure facility staff wore personal protective equipment (PPE) while providing care in a droplet isolation room. This affected one resident ( Resident #54) of two residents reviewed for isolation precautions and had the potential to affect six additional residents (#6, #12, #17, #32, #40, and #56) residing on the same unit. The facility census was 58. Findings included: Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included COVID-19 (11/02/23), diabetes, cardiomyopathy, disease of the gallbladder, chronic kidney disease, atrial fibrillation, and peripheral vascular disease. Review of the hospital laboratory test dated 11/02/23 revealed Resident #54 had tested positive for SAR-CoV-2 (COVID-19) via polymerase chain reaction (PCR) test. Review of the physician's orders dated 11/06/23 revealed Resident #54 was to be in droplet isolation due to being positive 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 review of the medical record and interview with the staff the facility failed to notify the physician or Nurse Practitioner Resident #46 was out of her insulin. This affected one resident (Resident #46) of three reviewed for insulin use. The facility census was 58. Findings included. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, diabetes, asthma, hypertension, iron deficiency anemia, major depression, anxiety disorder, insomnia, chronic right heart failure, congestive heart failure, hyperglycemia, migraines, and physical debility. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #46 had intact cognition and received insulin seven days a week. Review of the physician's orders revealed Resident #46 had an order for 80 units of Humulin 70/30 insulin twice daily dated 10/02/23. Review of the October 2023 Medication Administration Record revealed Resident #46 did not receive her 9:00 A.M. and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the pharmacy delivery sheets, and interviews with staff and resident, the facility did not ensure routine insulin was available to administer to Resident #46 according to the physician orders. This affected one resident (Resident #46) of three residents reviewed for insulin administration. The facility census was 58. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, diabetes, asthma, hypertension, iron deficiency anemia, major depression, anxiety disorder, insomnia, chronic right heart failure, congestive heart failure, hyperglycemia, migraines, and physical debility. Resident #46 was her own responsible party. Resident #46 received a diet of reduced concentrated sweets (RCS) , regular texture for diabetes management. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition and received insulin seven days a week. Review of…

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

Based on review of nursing schedules, employee time punch review and interviews, the facility failed to ensure a registered nurse was scheduled for eight consecutive hours every day. This had the potential to affect all 53 residents. Findings include: Review of nursing schedules and time punches for the period of 10/03/23 to 10/09/23 revealed there was no registered nurse (RN) coverage for eight consecutive hours on 10/08/23. During an interview on 10/11/23 at 9:00 A.M., Human Resource Director #118 verified the facility had no RN coverage for eight consecutive hours on Sunday, 10/08/23. This deficiency represents non-compliance investigated under Complaint Number OH00146702.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to promptly identify, assess, and treat potentially contagious/communicable rashes observed on residents who resided in the facility. The facility also failed to prohibit Registered Nurse (RN) #200, who reported having scabies, from direct resident contact. This affected six residents (#8, #14, #34, #44, #48 and #56) of six residents identified by the facility to have a rash and had the potential to affect all residents residing in the facility. Findings include: Interview on 08/02/23 at 7:34 A.M. with Registered Nurse (RN) #200 revealed she had scabies within the past week and had since been treated. Interview with the Director of Nursing (DON) on 08/02/23 at 10:18 A.M. revealed Residents #8, #14, #34, #44, #48 and #56 had all been in contact isolation since 07/29/23 and no further measures were being taken to ensure the containment of potential spreading of the rash. The DON revealed she did get a call from RN #200…

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

Based on record review and interview the facility failed to ensure Resident #214, Resident #215 and Resident #216 received a timely beneficiary notice when skilled services were discontinued. This affected three of three residents reviewed for beneficiary notices. Findings include: 1. Review of the Notice of Medicare Non-Coverage form for Resident #214 revealed the last covered day was 09/27/22. A verbal notification was indicated on 09/27/22. 2. Review of the Notice of Medicare Non-Coverage form for Resident #215 revealed the last covered day was 06/07/22. A verbal notification was indicated on 06/07/22. 3. Review of the Notice of Medicare Non-Coverage form for Resident #216 revealed the last covered day was 08/10/22. A verbal notification was indicated on 08/10/22. Interview on 10/13/22 at 10:40 A.M. with Social Service Designee/Human #209 verified the forms were dated the same as the last covered day.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure advanced directive orders were consistent across electronic and paper medical records. This affected two residents (Resident #5 and Resident #39) of three residents reviewed for advanced directives. The facility census was 58 residents. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 05/18/21 and diagnoses including emphysema, migraine, chronic kidney disease, anxiety disorder, bipolar disorder and depression. Review of Resident #5's 5-day minimum data set (MDS) assessment dated [DATE] revealed Resident #5 was rarely understood and required the extensive assistance of two staff for bed mobility and was totally dependent on two staff for transfers. Review of Resident #5's paper chart revealed her advanced directive on file was full code. Review of Resident #5's electronic medical record as of 10/11/22 revealed no advanced directive was identified and no physician's order 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 and interview, the facility failed to notify the resident representative of a change in health status and hospital transfer. This affected one (Resident #206) of three residents reviewed for notification of change. The facility census was 58. Findings include: Medical record review revealed Resident #206 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, aphasia, abnormal posture, heart disease, and psychotic disorder. The resident was discharged from the facility on 07/01/22. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/06/22, revealed a Brief Interview for Mental Status (BIM) score of 04, which indicated severely impaired cognition. The MDS further revealed Resident #206 required limited, one-person assistance with personal hygiene, toileting, bed mobility, and transfers. The resident wore a monitoring device due to wandering behaviors. Review of the admission record revealed Family Member #500 was listed as Resident #206's emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure care plans were revised as needed. This affected three residents (Resident #2, Resident #4 and Resident #46) of 21 residents reviewed for care planning. The facility census was 58 residents. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 11/29/21 and diagnoses including atrial fibrillation, epilepsy, alcohol abuse and chronic obstructive pulmonary disease. Review of Resident #46's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #46 was moderately cognitively impaired, required supervision for bed mobility and required limited assistance of one staff for personal hygiene and dressing. No falls were coded since the last assessment. Review of a fall investigation dated 04/16/22 revealed Resident #46 told the nurse he had fallen out of bed and hit his head. No injury was noted. Resident #46 was sent to the emergency room for evaluation and an immediate…

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, policy review, and interview, the facility failed to ensure fall interventions were in place for one (Resident #21) of three residents reviewed for falls. Findings include: Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, kyphosis, depressive disorder, and hearing loss. Review of the Plan of Care, dated 01/27/22 revealed Resident #21 was at risk for injuries from falls related to confusion and included the intervention to ensure the resident was wearing appropriate footwear when ambulating. Review of the Fall Assessment, dated 07/14/22, revealed Resident #21 was at a moderate risk of falling due to a history of falls and not using ambulatory aids. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/05/22, revealed Resident #21 resident required limited, one-person physical assistance for locomotion on the unit and dressing. The resident wore a monitoring device…

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 interviews the facility failed to assess Resident #48 before and after dialysis treatments. This affected one of two residents reviewed for dialysis. The census was 58. Findings include: Review of the medical record for Resident #48 revealed an admission date of 09/17/22. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, diabetes mellitus and atrial fibrillation. The 5-day Minimum Data Set assessment dated [DATE] revealed Resident #48 required extensive assistance for bed mobility, transfers, dressing and toileting. He was cognitively intact. Review of the September 2022 orders revealed Resident #48 was to receive dialysis treatments off-site on Tuesdays, Thursdays and Saturdays. His medications included Metoprolol Tartrate 25 milligrams (mg), give 0.5 tablet by mouth two times a day for high blood pressure. Review of the Medication Administration Record (MAR) for September 2022 revealed no order for blood pressures before and after dialysis. Review of…

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

Based on record review, interview and policy review, the facility failed to ensure pharmacy medication review recommendations were timely addressed and followed up upon. This affected one resident (Resident #44) of six residents reviewed for unnecessary medications. The facility census was 58 residents. Findings include: Review of Resident #44's medical record revealed an admission date of 11/01/21 and diagnoses including dementia without behavioral disturbance, anxiety, depression, moderate protein-calorie malnutrition, type two diabetes and gastro-esophageal reflux disease without esophagitis (GERD). Review of Resident #44's plan of care for GERD dated 11/11/21 revealed interventions including give medications as ordered and monitor/document side effects and effectiveness. Review of a medication review dated 06/25/22 for Resident #44 per Pharmacist #245 revealed Resident #44 had been taking protonix (medication that reduces stomach acid) 40 milligrams (mg) BID (twice a day) since 11/19/21. The pharmacist recommended documented review for continued use as was required after 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, interview, record review and policy review the facility failed to ensure resident records were complete and accurate. This affected three residents (Resident #3, Resident #46 and Resident #54) of 21 residents reviewed for documentation. The facility census was 58 residents. Findings include: 1. Review of Resident #54's medical record revealed an admission date of 09/10/19 and diagnoses including chronic obstructive pulmonary disease with acute exacerbation, hemiplegia and hemiparesis following cerebral infarction, morbid obesity, acute and chronic respiratory failure, type two diabetes, COVID-19, dementia without behavioral disturbance and tracheostomy status. Review of Resident #54's physician's orders revealed an order dated 05/04/20 for tracheostomy suction as needed; an order dated 05/04/20 for tracheostomy assess skin around stoma site and under ties during tracheostomy care; an order dated 05/04/20 for tracheostomy change ties when soiled and as needed; an order dated 05/04/20 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.

Based on record review and staff interview the facility failed to implement their abuse policy and procedure to ensure screening procedures included checking all staff members against the Nurse Aide Registry (NAR) to determine whether the employee had a finding of abuse, neglect and/or misappropriation. The facility failed to check the Director of Nursing (DON), Licensed Practical Nurse (LPN) #508, Registered Nurse (RN) #515, and Maintenance Supervisor (MS) #579. This affected four of eight new employees reviewed and had the potential to affect all 61 residents residing in the facility. Findings include: During personnel file review on 10/16/19 at 9:15 A.M. with Human Resources/Social Services (HR/SS) #593, the following four new employees were reviewed: The DON, whose hire date was 09/23/19; LPN #508, whose hire date was 08/03/19; RN #515, whose hire date was 07/11/19; and MS #579, whose hire date was 02/08/19. There was no evidence in the personnel file for each of these employees to ensure screening procedures included a check of the employee against the Nurse Aid Registry (NAR)…

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 acceptable infection control standards to prevent the spread of infection related to the collection of soiled laundry, the cleaning of resident rooms for residents who have Clostridium Difficle (C Diff) infections, the disposal of items in a sharps container and during blood glucose testing using a shared glucometer. This affected two residents (#17 and #22) and had the potential to affect all 61 residents residing in the facility. Findings include: 1. On 10/17/19 at 11:30 A.M. Housekeeper (HSKP) #554 was observed collecting soiled linen from the 200 hall soiled utility room. HSKP #554 was observed with a cloth laundry collection cart which was heaped with soiled clothing in trash bags and a white bath blanket folded in thirds and laying on top. The cart was heaped approximately one foot over the top edge. HSKP #554 had used the cart to prop the soiled utility room door open and was observed without a gown or gloves on. HSKP #554 was observed taking dirty linen, which were in clear trash bags, from 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 and interview the facility failed to provide restorative ambulation services as planned, failed to complete accurate restorative assessments, failed to ensure restorative delivery records were completed in a manner which would permit a thorough assessment, and failed to address declines in participation in a timely manner. This affected one resident (#9) of two residents reviewed for activities of daily living. Findings include: Review of Resident #9's medical record revealed a re-entry date of 09/10/18. Diagnoses included post polio syndrome, low back pain, peripheral vascular disease (PVD), repeated falls, pain in knee, cognitive communication deficit, and history of falling. A physical therapy (PT) Discharge summary dated [DATE] indicated discharge recommendations included a restorative nursing program (RNP) to maintain her level of performance and to prevent decline. Development of and instruction in an RNP for ambulation was completed with the interdisciplinary team. The discharge…

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 #33 and Resident #50 received appropriate care and services. This affected two residents (#33 and #50) of three residents reviewed for dignity and respect. Findings include: 1. Resident #33 was admitted on [DATE] with diagnoses including but not limited to bariatric surgery status, muscle weakness, lack of coordination, pain in right and left shoulders, chronic obstructive pulmonary disease, unspecified bipolar disorder, schizophrenia major depressive disorder, and anxiety disorder. Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was alert and oriented and her cognition was intact. She required extensive one person assistance with bed mobility and toileting, required two person extensive assistance from staff for transfers, and she was occasionally incontinent of urine and was always continent of bowel. Interview on 10/15/19 at 11:20 A.M. with Resident #33 revealed she has had to wait one hour and 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, record review and interview the facility failed to implement a bowel protocol for Resident #57 to address the resident's constipation and failed to ensure an assessment and treatment were implemented for Resident #29 related to a non-pressure related skin injury. This affected one resident (#57) of 27 residents interviewed related to bowel status and one resident (#29) of 27 residents observed for skin integrity. Findings include: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, major depressive disorder, anxiety disorder, and symptoms and signs involving cognitive functions and awareness. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 09/24/19, revealed Resident #57 had mild cognitive impairment and no behaviors were listed. Review of Resident #57's care plans, dated 09/24/19, revealed a care plan which stated Resident #57 was resistive to care and taking medications for bowel movements secondary 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 observation, record review and interview the facility failed to complete an accurate pressure ulcer assessment for Resident #8 following the resident's readmission from the hospital. This affected one resident (#8) of four residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #8 was initially admitted to the facility on [DATE] with diagnoses including osteomyelitis to both right and left ankles and feet, type two diabetes, and peripheral vascular disease. Review of Resident #8's medical record revealed on 08/08/19 an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer was identified on Resident #8's right lateral heel. Further review of Resident #8's medical record revealed Resident #8 was admitted to the hospital on [DATE] with diagnoses of acute exacerbation of chronic obstructive pulmonary disease and congestive heart failure. The last wound assessment prior to Resident #8's hospitalization was on 10/03/19 which documented Resident #8's right…

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 provide restorative nursing services for range of motion (ROM) in accordance with Resident #9's plan of care. This affected one resident (#9) of 26 residents screened for range of motion. Findings include: Review of Resident #9's medical record revealed an admission date of 09/10/18. Diagnoses included post polio syndrome, low back pain, pain in the knee, cognitive communication deficit, history of falling, and history of malignant neoplasm of the large intestine and ovary. An Occupational Therapy (OT) evaluation dated 09/11/18 revealed Resident #9 had limitations in range of motion (ROM) of bilateral upper extremities which were flaccid. A Physical Therapy (PT) evaluation dated 09/11/18 indicated ROM of bilateral lower extremities was within functional limits. Resident #9's OT was discontinued on 09/17/18 due to Resident #9's refusal to participate. A PT discharge summary revealed PT was discontinued 12/28/19. Review of a restorative nursing care plan dated 02/12/19 revealed restorative needs were identified for ambulation…

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 provide a timely dietary consult and failed to administer tube feeding nutrition as ordered for Resident #12 to prevent weight loss. This affected one resident (#12) of two residents reviewed for nutrition. Findings include: Review of Resident #12's medical record revealed diagnoses including dysphagia (difficulty or discomfort with swallowing) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). a. A physician's order dated 03/28/19 (date of admission) revealed Resident #12 was to have Jevity 1.5 administered five times a day via bolus. A dietary note dated 04/04/19 at 12:17 P.M. indicated Resident #12 reported he felt too full. Interviews with nursing staff revealed Resident #12 refused his tube feeding at times due to being too full. The dietitian recommended changing the tube feed to Jevity 1.5 (one container) six times a day. Resident #12 had a physician's order 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.

Based on observation, record review and interview the facility failed to deliver nutrition through a feeding tube in a manner which would prevent microbial growth. This affected one resident (#12) of one resident reviewed for enteral/feeding tubes. The facility identified three residents receiving tube feedings. Findings include: Review of Resident #12's medical record revealed diagnoses including dysphagia (difficulty or discomfort with swallowing) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review revealed Resident #12 had a physician's order for nothing by mouth and for the administration of Jevity 1.5 at a rate of 68 milliliters per hour (ml/hr) for 22 hours a day. Orders revealed the Jevity was to be run between the hours of 6:00 A.M. and 4:00 A.M. On 10/15/19 at 9:45 A.M., Resident #12 was observed lying in bed. A kangaroo bag was running via pump. The bag was labeled Jevity with the date written on it but not the time it was hung. There was approximately 700 cubic centimeters (cc's) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview facility failed to implement a comprehensive and individualized pain management program including the administration of pain medication for Resident #48 as ordered. This affected one resident (#48) of two residents reviewed for pain. Findings include: Resident #48 was admitted on [DATE] with diagnoses including drug induced subacute dyskinesia (involuntary muscle movements), altered mental status, diabetic neuropathy, Huntington's disease, and chronic pain syndrome. Resident #48's physician orders dated 08/01/19, revealed she was ordered Morphine Sulfate extended release (a narcotic opioid pain medication), one tablet by mouth every eight hours for pain. It was scheduled for administration at 6:00 A.M., 2:00 P.M., and 10:00 P.M. Resident #48's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired. Review of Resident #48's September 2019 Controlled Drug Records for Morphine, which included charting by the nurse as signing out…

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 the justified use of psychoactive medication for Resident #38. This affected one resident (#38) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #38 was initially admitted to the facility on [DATE] with diagnoses which included major depressive disorder with psychotic symptoms, dementia with behavioral disturbance, paranoid personality disorder, anxiety disorder, and visual hallucinations. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/19 revealed Resident #38 was cognitively impaired and had displayed mild depressive indicators scoring a six on the depression scale, and no behaviors. Review of Resident #38's medical record revealed Resident #38 regularly saw a psychiatrist and their nurse practitioner. The psychiatrist and nurse practitioner also managed Resident #38's psychotropic medications. Review of Resident #38's October 2019 medication…

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.