Ridgewood Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, and within prescribed time frames, to prevent significant medication errors. This affected three (#16, #24, and #141) for four residents reviewed for the administration of medications in a facility census of 39. Findings include: 1. Review of Resident #24's medical record noted physician orders including the narcotic pain medication oxycodone five (5) milligrams (mg) two times daily for pain, scheduled for 9:00 A.M. and 9:00 P.M. and ordered on 02/27/25; the antianxiety medication Ativan 0.25 mg every morning and at bedtime, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 04/07/25; the blood pressure and heart failure medication Coreg 6.25 mg every morning and at bedtime, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 05/07/24; the nerve pain medication gabapentin 600 mg three times daily, scheduled for 7:00 A.M., 2:00 P.M., 7:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure wound care treatments were completed per physician orders. This affected one resident (#18) of three residents reviewed for wound care. The facility identified five residents with wounds. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/05/24. Diagnoses included paraplegia, chronic obstructive pulmonary disease, pressure ulcer of sacral region stage four, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. The resident was at risk for pressure ulcers and had a stage four pressure ulcer present on admission. Review of the skin risk assessment dated [DATE] revealed the resident was at moderate risk for skin breakdown. Review of a physician order dated 01/29/25 revealed to cleanse sacral wound with wound cleanser, apply calcium alginate…

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 the medical record, observation, interview, and policy review, the facility failed to clarify and implement physician orders for the care of a tracheostomy and further failed to provide tracheostomy care. This affected one resident (#19) of two residents reviewed for respiratory care. The facility identified 19 residents receiving respiratory care. The facility census was 44. Findings include: Review of the medical record for Resident #19 revealed an admission date of 02/06/25. Diagnoses included acute respiratory failure, epilepsy, pneumonia, hemiplegia, and hypertension. Review of the hospital discharge orders dated 02/06/25 revealed orders for tracheostomy care twice a day and tracheostomy suction as needed. Review of the baseline care plan dated 02/06/25 revealed tracheostomy cannula size six, suction, oxygen. There were no interventions to provide tracheostomy care and no instructions regarding the frequency of suctioning. Review of the admission physician orders for 02/06/25 revealed the resident had no orders in place for tracheostomy care or tracheostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of the Centers for Medicare and Medicaid Services (CMS) Provider History Profile document, the facility failed to have an effective quality assurance and performance improvement (QAPI) program to address repeated deficiencies identified during four consecutive comprehensive surveys. This had the potential to affected all 44 residents in the facility. The census was 44. Findings include: Review of the CMS Provider History Profile document, with Certification and Survey Provider Enhanced Reporting (CASPER) system data, last updated 12/10/24, revealed the facility was issued a deficiency for not administering medications as ordered resulting in significant medication errors on the three previous comprehensive surveys in August 2023, January 2024, and 07/18/24. During the current comprehensive survey, with exit date 12/19/24, the facility was cited for significant medication errors for the four consecutive comprehensive survey. 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 observation, staff interview, medical record review, review of a medication package insert, and review of facility policies, the facility failed to ensure water temperature testing was completed as part of the facility Legionella prevention program. In addition, the facility failed to ensure staff wore proper personal protective equipment during resident care for a resident (#13) on enhanced barrier precautions and failed to cleanse a resident's (#24) insulin dispensing pen prior to affixing a needle for administration. This deficient practice had the potential to affect all 44 residents residing in the facility. The facility census was 44. Findings Include: 1. Review of the facility water temperature logs on 12/19/24 at 8:35 A.M. revealed water temperature testing was absent from 10/01/24 through 12/19/24. Interview with Maintenance Supervisor #631 on 12/19/24 at 8:40 A.M. revealed he had been employed at the facility for a short time and was unaware of the Legionella policy. Interview with Regional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, review of medical records, review of a behavior contract, review of facility equipment logs, and review of facility policies, the facility failed to ensure emergency crash carts were completely stocked per facility policy. This had the potential to affect 33 (#1, #3, #4, #5, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #23, #24, #27, #28, #29, #30, #31, #32, #33, #35, #38, #39, #40, #41, #44, #45, #46, #48, and #50) residents identified by the facility as being full code (the resident wishes to receive resuscitation and all live saving measures in the event of a cardiac or respiratory arrest). In addition, the facility failed to ensure smoking materials were stored safely for one (#28) of one residents reviewed for smoking and failed to ensure one (#43) of one residents reviewed for accidents and hazards was transferred with the appropriate level of assistance to prevent falls. The facility census was 44. Findings Include: 1. Interview and 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 medical record review and staff interview, the facility failed to ensure residents who were being discharged from Medicare Part A services received timely notification. This affected three (#25, #49, and #104) of three residents reviewed for beneficiary notices. The facility census was 44. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 11/25/22. Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #25 revealed his services would end on 11/23/24. Further review revealed Resident #25 was notified his services were ending via a telephone call on 11/22/24. 2. Review of the medical record for Resident #49 revealed an admission date of 11/07/24 and a discharge date of 12/11/24. Review of the NOMNC for Resident #49 revealed her services ended on 12/11/24. Further review revealed Resident #49 was notified on 12/10/24 regarding the end of her services. 3. Review of the medical record for Resident #104 revealed an admission date of 06/13/24 and a discharge date of 09/14/24. Review of the NOMNC for Resident #104 revealed…

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 self-reported incidents (SRIs) and facility investigation, review of a witness statement, and staff interview, the facility failed to ensure residents were free from abuse. This affected two (#7 and #23) of three residents reviewed for abuse. The facility census was 44. Findings include: 1. Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of an unspecified cerebral artery, unspecified dementia, schizoaffective disorder bipolar type, essential hypertension, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. 2. Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included dislocation of the C1/C2 cervical vertebrae, atherosclerotic heart disease of native coronary, Parkinson's disease, chronic viral hepatitis C, schizoaffective…

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 implement ordered interventions to aid in producing a bowel movement. This affected one (#15) of one residents reviewed for bowel and bladder. The facility census was 44. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, muscle wasting and atrophy, chronic pulmonary edema, heart failure, dyspnea, hypotension, polyneuropathy, essential hypertensive, chronic systolic heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired, was always incontinent of bowel, and received hospice services. Review of the care plan dated 07/15/24 revealed Resident #15 was at risk for pain due to disease process and interventions included to monitor for side effects of pain medication including to observe for constipation. Review of a physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure wound care was completed timely and as ordered. This affected one (#9) of two residents reviewed for wound care. The facility census was 44. Findings included: Review of Resident #9's medical record revealed an admission date of 03/02/20. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and malnutrition. The resident was admitted to hospice on 11/12/24. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a low cognitive function. The resident was dependent for all activities of daily living except eating. The resident was also dependent on staff for rolling left and right. Review of Resident #9's current care plan revealed she had the potential for skin impairment related to fragile skin, impaired mobility, and incontinence. The resident had a stage two (partial-thickness skin loss with exposed dermis) sacral pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of a medication manufacturer package insert, the facility failed to ensure residents received insulin as ordered which resulted in a significant medication error. This affected one (#13) of three residents observed during medication administration. The facility identified 10 residents with orders for insulin in a facility census of 44. Findings Include: Review of Resident #13's medical record revealed an admission date of 10/26/18. Diagnoses included epilepsy, iron deficiency anemia, heart failure, primary osteoarthritis, insomnia, hyperlipidemia, hypertension, atrial fibrillation, type two diabetes mellitus, post-traumatic stress disorder, and major depressive disorder. Review of Resident #13's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #13's current physician orders as of 12/18/24 revealed the resident was to receive Novolog insulin eight (8) units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of medication manufacturer package inserts, and review of facility policy, the facility failed to ensure that insulin was labeled appropriately. This affected two (#17 and #46) of 10 residents with orders for insulin. The facility census was 44. Findings Include: 1. Review of Resident #17's medical record revealed an admission date of 05/27/24. Diagnoses included nonrheumatic aortic stenosis, hyperlipidemia, type two diabetes mellitus, hypertension, mild protein-calorie malnutrition, obstructive sleep apnea, major depressive disorder, anxiety disorder, insomnia, and bilateral primary osteoarthritis. Review of Resident #17's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] the resident was cognitively intact. Observation on 12/16/24 at 9:11 A.M. of a medication cart on the South Hall revealed a Basaglar insulin KwikPen that was open and approximately one-quarter used. There was no date documented on the Basaglar insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medication administration was accurately documented. This affected one (#24) of four residents reviewed for medication administration. The facility census was 44. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/05/24 with a diagnosis of type II diabetes mellitus. Review of the admission comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition. Review of a physician order dated 09/05/24 revealed Resident #24 received insulin glargine solution 100 units per milliliter with instructions to inject 45 units subcutaneously (SQ) every morning and at bedtime for diabetes. Review of the medication administration record (MAR) for Resident #24 revealed insulin glargine was scheduled to be given at 7:00 A.M. and was administered on 12/17/24 at 7:54 A.M. Further review revealed Resident #24's blood glucose…

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 policy review, the facility failed to ensure the kitchen was kept in a sanitary manner. This had the potential to affect all 51 residents residing in the facility. The facility census was 51. Findings include: Observation on 10/09/24 beginning at 8:20 A.M. of the facility kitchen revealed there were several areas of broken floor tile trim leading into the dishwasher room. There was heavy dust buildup on the walls near the kitchen entrance. Further observations revealed there was a buildup up of food debris in the three grease traps underneath the cook top stove. Continued observations revealed there was a buildup of debris on the floor on the side and behind the cook top stove. Interview on 10/09/24 at 8:28 A.M., Dietary Manager (DM) #122 stated stated the kitchen was deep cleaned every six months. DM #122 verified the broken kitchen tiles, dust build up on the walls, the buildup of debris on the floor next to the cook top stove. DM #122 also verified the buildup of food debris in the grease traps and stated the grease traps were cleaned…

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 NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interviews and policy review, the facility failed to ensure new admission wound care orders were timely clarified and completed per physician orders. This affected one (#52) of three residents reviewed for wound care. The facility census was 51. Findings include: Review of the medical record for Resident #52 revealed an admission date of 09/16/24 and a discharge date of 10/01/24. Diagnoses included malignant neoplasm of the bladder, hematuria, chronic kidney disease, acute kidney failure, diabetes mellitus type two, end stage renal disease and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #52 had intact cognition. Further review of the MDS revealed the resident had surgical wounds and received surgical wound care. Review of hospital documentation dated 09/15/24 revealed Resident #52…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of the State Fire Marshal Report, review of facility assessment, and review of the policy, the facility failed to maintain the sprinkler systems in operational status for fire safety, failed to ensure fire/smoke barriers were maintained, failed to notify the Ohio Department of Health (ODH) of the facility being under a fire watch, and further failed to ensure fire watches were being conducted correctly. This has the potential to affect all residents in the facility. The facility census was 52. Findings include: 1. Review of the State Fire Marshal Fire Safety Inspection Report dated 05/20/24 revealed the fire protection system had not been inspected, tested and maintained as required and two violations were issued. The report indicated the dry sprinkler system had several leaks over the weekend. Observation of many pin holes and repairs in the sprinkler system. The damaged pipe will need replaced. The report also indicated an obstruction investigation was required 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, staff interview, and review of facility assessment, the facility failed to maintain a safe and clean environment after the facility had a water leak causing damage. This has the potential to affect all residents in the facility. The facility census was 52. Findings include: Observation on 06/06/24, during the initial tour of the facility, between 6:45 A.M. and 7:30 A.M., revealed a missing section of the ceiling on the north hall approximately 8 feet wide by 8 feet long with plastic stabled loosely to the exposed wood trusses, an area approximately two feet wide by two feet long with loosely screwed drywall to a patched ceiling in the south hall just inside the fire doors and in room [ROOM NUMBER], several bath towels with brownish-yellow dried discoloration were noted on the floor of the unoccupied room (215), below a sagging ceiling with deep cracks approximately four feet wide by eight feet long. Interview on 06/06/24 at 12:00 P.M., with the Assistant Director of Nursing (ADON) #505…

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, resident interview, staff interview, review of facility assessment, review of the housekeeping daily cleaning reports, and review of the exterminator inspection report, the facility failed to maintain an effective pest control program. This directly affected one resident (#51) with the potential to affect all residents of the facility. The facility census was 52. Findings include: Observation on 06/06/24 at 8:45 A.M., during the tour of the facility, revealed a snap trap (mouse trap) on the floor in the office of the Minimum Data Set (MDS) Nurse #500. The snap trap was along the wall on the left side of the office as you entered. Interview with the MDS Nurse #500, at the time of the observation, verified mice were seen in the building over the weekend of June 1st and June 2nd, 2024. MDS Nurse #500 added he killed a mouse earlier in the week in the office and have seen mice in the therapy room. Interview on 06/06/24 at 9:05 A.M., with Occupational Therapist #501 in the therapy room verified mice have been seen in the therapy room this week and a snap trap is…

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, medication admin audit report, and policy, the facility failed to administer medications in the time frame ordered by the physician. This affected twelve residents (#3, #8, #9, #10, #11, #16, #17, #18, #20, #23, #24, and #26) who resided on the north front hallway. The facility census was 64. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 01/30/24 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, type two diabetes, hypertension, cocaine abuse, and chronic pain. Review of the medication admin audit report dated 02/20/24 revealed antifungal powder two percent (%) for itching and Tylenol 325 milligrams (mg) two tablets for pain was given at 11:43 A.M. and was scheduled for 7:00 A.M. - 10:00 A.M. 2. Review of the medical record for Resident #8 revealed an admission date of 12/19/23 with diagnoses of COPD, repeated falls, bipolar, coronary artery disease, hyperlipidemia, anxiety, and major depressive disorder. Observation on 02/20/24 at 11:20 A.M. 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, the facility failed to fill out a discharge notice completely. This affected one (Resident #65) of two residents reviewed for facility initiated discharges. The facility census was 64. Findings include: Review of medical record for Former Resident (FR) #65 revealed an admission date of 12/20/23 and a discharge date of 02/13/24. Diagnoses included alcohol abuse, cocaine abuse, depression, transient cerebral ischemic attack, chronic obstructive pulmonary disease, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] for FR #65 revealed the resident was cognitively intact. FR #65 was independent to set-up/supervision for activities of daily living. Review of the discharge notice dated 02/13/24 for FR #65 revealed the effective date of discharge was left blank and the reason for discharge was not marked. Interview on 02/21/24 at 11:55 A.M. with the Administrator verified FR #65's discharge notice did not have the discharge date on the form and verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a safe an orderly discharge. This affected one (Resident #65) of two residents reviewed for facility initiated discharges. The facility census was 64. Findings include: Review of the medical record for Former Resident (FR) #65 revealed an admission date of 12/20/23 and a discharge date of 02/13/24. Diagnoses included alcohol abuse, cocaine abuse, depression, transient cerebral ischemic attack, chronic obstructive pulmonary disease, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] for FR #65 revealed the resident was cognitively intact. FR #65 was independent to set-up/supervision for activities of daily living. Review of the care plan dated 01/05/24 for FR #65 revealed no care plan for behaviors/aggression or sexual misconduct. Review of the physician orders for FR #65 revealed 15-minute safety checks for behaviors, please call admin with any issues, Tylenol 325 milligrams (mg) every six hours as needed for pain,…

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 policy review, the facility failed to ensure a medication error rate less than five percent with 13 medication errors out of 33 opportunities resulting in a medication error rate of 39.39%. This affected one (Resident #8) of four observed for medication pass. The facility census was 64. Findings include: Review of the medical record for Resident #8 revealed an admission date of 12/19/23 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), repeated falls, bipolar, coronary artery disease, hyperlipidemia, anxiety, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #8 required set-up/clean-up to supervision for activities of daily living. Observation on 02/20/24 at 11:20 A.M. of medication administration for Resident #8 revealed the resident received airsupra aerosol 90-80 micrograms (mcg) two puffs for COPD, aripiprazole (bipolar) 15 milligrams (mg),…

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, resident and staff interview, and facility policy, the facility failed to ensure residents who smoked had safe interventions in place. This affected one (Resident #51) of three residents reviewed for smoking. The facility census was 73. Findings include: Review of the medical record revealed Resident #51 was admitted on [DATE]. Diagnoses included quadriplegia, neuromuscular dysfunction of bladder, anxiety disorder, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact and dependent for bathing/showering, personal hygiene, transfers, and toileting. Review of the care plan initiated 07/29/20 revealed Resident #51 is a smoker and will not smoke without supervision through the review date. Interventions included to instruct resident about smoking risks and hazards and about smoking cessation aides that are available, instruct resident about the facility policy on smoking: locations,…

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 the medical record, staff interview, and policy review, the facility failed to ensure residents were offered pneumococcal vaccinations. This affected two (Residents #52, #11) of five reviewed for immunizations. The facility census was 58. Findings include 1. Review of the medical record for Resident #52 revealed an admission date of 11/03/23. Diagnoses included type two diabetes mellitus and hypertension. Review of the immunization records for Resident #52 revealed no documentation the resident was offered a pneumococcal vaccination. 2. Review of the medical record for Resident #11 revealed an admission date of 09/29/23. Diagnoses included type two diabetes mellitus, hypertension, dementia, and chronic systolic heart failure. Review of the immunization records for Resident #11 revealed no documentation the resident was offered a pneumococcal vaccination. Interview on 12/12/23 at 1:15 P.M. with the Director of Nursing (DON) revealed no pneumococcal vaccinations had been offered to Resident #11 and Resident #52. Review of the policy, Pneumococcal Vaccine, last…

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 the medical record, staff interviews, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure residents were offered the updated COVID-19 vaccination. This affected three (Residents #52, #11, #16) of five reviewed for vaccinations. The facility census was 58. Findings include 1. Review of the medical record for Resident #52 revealed an admission date of 11/03/23. Diagnoses included type two diabetes mellitus and hypertension. Review of the immunization records for Resident #52 revealed no documentation the resident was offered or received an updated COVID-19 vaccination. 2. Review of the medical record for Resident #11 revealed an admission date of 09/29/23. Diagnoses included type two diabetes mellitus, hypertension, dementia, and chronic systolic heart failure. Review of the immunization records for Resident #11 revealed no documentation the resident was offered or received an updated COVID-19 vaccination. 3. Review of the medical record for Resident #16 revealed an admission date of 09/26/23.…

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 Self-Reported Incidents (SRI), staff interview, and review of facility policy, the facility failed to complete a thorough investigation regarding resident-to-resident abuse. This affected two (Residents #1 and #59) of three residents review for abuse. The facility census was 53. Findings include: 1. Review of the closed medical record revealed Resident #1 was admitted on [DATE] and discharged on 08/15/23. Diagnoses included paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, essential (primary) hypertension, hypothyroidism, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Resident #1 required one person limited assistance with bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident received antipsychotic, antianxiety, 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, observation, staff interview, review of resident smoking agreement, and review of facility policy, the facility failed to ensure residents who smoked had safety interventions in place. This affected two (Residents #31 and #56) of three residents reviewed for safe smoking. In addition, the facility failed to ensure fall interventions were in place for Resident #261. This affected one (Resident #261) of one resident reviewed for falls. Additionally, the facility failed to ensure sharps were disposed of in a safe manner. This had the potential to affect three (Residents #29, #54, and #261) who were cognitively impaired and independently mobile on the south hall. Furthermore, the facility failed to ensure residents had access to a bathroom call light/pull-cord in a bathroom assessable to residents. This had the potential to affect 30 (Residents #6, #7, #8, #10, #11, #13, #16, #17, #18 #19, #20, #22, #23, #24, #26, #30, #31, #35, #36, #37, #39, #41, #42, #43, #46, #47, #48, #49, #211,…

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.