Medina Center For Rehabilitation And Nursing

Based on record review and staff interview, the facility failed to timely address and respond to voiced concerns regarding resident care and life in the facility identified by residents in resident council and food committee meetings. This had the potential to affect all residents residing in the facility. The facility census was 73. Findings include: Review of the resident council meeting minutes revealed the following documented concerns regarding staffing: - During the meeting dated 11/30/23, residents reported nightshift could be nicer. - During the meeting dated 01/25/24, residents reported call lights need answered faster. - During the meeting dated 04/25/24, residents reported nurses need to be nicer and more caring. - During the meeting dated 06/27/24, residents reported nurses need to be more caring and night aides need to do their jobs. - During the meeting dated 07/25/24, residents reported night aides need to do their jobs. - During the meeting dated 08/29/24, residents reported night shift needed to get better, and the staff on night shift do whatever they want. 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.

Based on record review, resident interview, staff interview, review of the resident council meeting minutes, review of the grievance log, and facility policy review, the failed to be adequately staffed to meet the needs of its residents. This had the potential to affect all residents. The facility census was 73. Findings include: 1. Interview on 02/09/24 at 8:45 A.M. with Resident #3 revealed concerns related to sufficient facility staffing, notably on the weekends and night shift. 2. Interview on 02/09/24 at 2:02 P.M. with Resident #44 revealed concerns related to sufficient facility staffing. Resident #1 further stated that he has missed medications due to insufficient facility staffing and is of the belief many of his skin related to issues could have been solved by increased staffing levels. 3. Interview on 02/10/24 at 9:12 A.M. with Resident #1 revealed concerns related to sufficient facility staffing. Resident #1 stated call light response time is often up to four hours. 4. Interview on 02/19/24 at 2:30 P.M. with the family member of Resident #54 revealed staffing is horrible.…

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 ensure the service of a Registered Nurse (RN) for at least eight hours a day seven days a week as required. This had the potential to affect all residents. The facility census was 73. Findings include: Review of the staffing schedule and posted nursing staff information for 12/21/24 revealed the facility did not have eight hours of Registered Nurse (RN) coverage as required. The facility had evidence of only four total hours of RN coverage on 12/21/24. Interview with Scheduler #111 on 02/19/25 at 11:11 A.M. verified the lack of required RN hours. This deficiency represents non-compliance investigated under Complaint Number OH00161426 and OH00161390.

Based on observation, resident interview, and record review revealed the facility failed to provide palatable food to residents. This had the potential to affect all residents residing in the facility. The facility census was 73. Findings include: Review of food committee meeting minutes from July 2024 through February 2025 revealed residents had concerns related to cold food and coffee, the facility not using hot packs, and food palatability. Review of grievance logs between August 2024 and February 2025 revealed on 08/26/24, Resident #56 reported there were no hot plates (to keep food warm) provided and that residents were unhappy with their meals. On 09/09/24, Resident #10 reported their food was cold. On 01/30/25, Resident #6 reported the meat is trash. Interview on 02/09/25 at 10:30 AM with Resident #46 revealed the food is bland and usually not warm. Interview on 02/09/25 at 11:15 A.M. with Resident #51 revealed the food does not taste good and is cold. Interview on 02/09/25 at 01:57 P.M. with Resident #36 revealed the food is nasty. An observation and interview on 02/09/25 at…

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

Based on observation, interview, and review of facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 73 residents. Findings include: 1. Observation and interview on 02/09/25 between 8:52 A.M. and 9:35 A.M. with [NAME] #118 during a kitchen tour revealed the following: a. One bottle of vanilla with expiration date of 02/10/24. b. The shelf under tray line had rust, food debris, and crumbs on it. c. The ice machine had noticeable rust on the door hinge. d. Significant areas of crumbs and food debris were observed on the floor in the dry storage area. e. The air vent next to the food preparation area was rusted and had a thick layer of grime on it. f. A large brown stain and crack on ceiling above the three-compartment sink was noted. g. The seal on the refrigerator door was falling off and not attached to door. h .The walk-in freezer had an ice cream tub wedged underneath a pipe. The pipe had dripped water onto the ice cream tub and a large ice chunk had formed on the lid. The ice cream tub 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.

Based on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 73 residents in the building. Findings include: Observation on 02/09/25 at 9:10 A.M. revealed one of two outside dumpsters did not have a lid and there were multiple latex gloves, a large cardboard box near the woods and other miscellaneous trash on ground around the dumpster. Additional trash and debris was observed to have blown into the grass and woods behind the dumpster. Observation and interview on 02/09/25 at 3:48 P.M. with Dietary Manager (DM) #114 verified that the dumpster did not have a cover and confirmed observation of trash around dumpster.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to maintain an infection prevention program to prevent, recognize, and control transmission of communicable disease. This affected two residents (#32 and #33) of four residents sampled and had the potential to affect all facility residents. The facility census was 73. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 04/14/22 and a discharge date of 12/30/24. Diagnoses included cognitive communication deficit, moderate intellectual disabilities, abnormalities of gait and mobility, anxiety, and muscle weakness. Review of Resident #32's physician orders revealed the resident was to attend an outside adult day program Monday through Friday. An order dated 12/26/24 revealed the resident was to have skin sweeps performed twice daily, every day and night shift for monitoring for three days. Review of an email dated 12/19/24 at 2:03 P.M. from the adult day program to the…

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

Based on record review, interview, and review of facility policy, the facility failed to designate a certified infection preventionist responsible for the infection control and prevention program. This affected one resident (Resident #32) of four residents sampled and had the potential to affect all facility residents. Facility census was 73. Findings include: Review of the Infection Preventionist certification from The Centers for Disease Control and Prevention (CDC) revealed the Assistant Director of Nursing (ADON) #102 completed the Nursing Home Infection Preventionist Training Course, (#WB4448R) on 02/10/25. Review of the facility staffing records during the annual survey revealed a part-time qualified infection control preventionist was not present in the building as required. Review of the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting documentation revealed an Infection Preventionist was not in attendance on 10/23/24, 11/6/24, 01/16/25. No other documentation was provided. Interview on 02/20/25 at 12:09 P.M., the VP of Clinical Operations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to maintain a safe and sanitary resident environment. This affected one (Resident #23) of 18 residents observed for environment. Findings include: Review of the medical record for Resident #23 noted an admission date of 02/28/18. Diagnoses included unspecified dementia, without behavioral disturbance, type two diabetes mellitus, cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] noted Resident #23 had intact cognition. Observation on 02/09/25 at 10:30 A.M. of Resident #23's room noted two large holes in the wall measuring approximately six inches in width by seven inches in length behind the headboard and miscellaneous debris including dust, food wrappers, and crumbs. Interview during observations, Resident #23 stated the holes in the wall were there since he moved in. Interview on 02/09/25 at 10:49 A.M., Housekeeper #117 verified the observations. Observations and interview on…

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

Based on observation, interview, and policy review the facility failed to secure protected health information from the public and failed to protect the resident right to privacy. This affected one resident (#45) of four residents reviewed for privacy. The facility census was 73. Findings include: Observation on 02/11/25 at 10:46 A.M. of the facility's west hallway revealed an enclosed nursing station with a facility laptop open on top of the west medication cart parked outside the nurse station. Observation of the computer revealed Resident #45's medical chart was open to private medical information and visible to the public hallway. During the observation, two visitors and various residents and staff members were present in the direct vicinity. Interview on 02/11/25 at 10:48 A.M., the Regional Administrator #206 confirmed the facility laptop was open to protected health information and was visible to the public hallway. The Regional Administrator was observed shutting the laptop. Interview on 02/11/25 at 10:56 A.M., the Licensed Practical Nurse (LPN) #195 returned to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to create a plan of care for a resident who had a significant change in condition following an injury. This affected one (Resident #24) of five residents reviewed for care planning. The facility census was 73. Findings include: Review of the medical record for Resident #24 noted an admission date of 09/19/22. Diagnoses included chronic obstructive pulmonary disease, unspecified, muscle wasting and atrophy, major depressive disorder, and other lack of coordination. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] noted Resident #24 had intact cognition. Resident #24 required maximum assistance for mobility. Further review of the MDS's noted no documentation indicating Resident #24 had a significant change in condition. Review of the plan of care noted Resident #24 was at risk for falls and had an activity of daily living self-care deficit. No plan of care was created to indicate Resident #24 had a fracture 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 record review, interview, and facility policy review, the facility failed to complete routine oral care for residents who required assistance. This affected one resident (#47) of five residents reviewed for activities of daily living. The facility census was 73. Findings include: Review of the medical record for Resident #47 noted an admission date of 04/01/23. Diagnoses included unspecified dementia, unspecified severity with agitation, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] noted Resident #47 had impaired cognition. Resident #47 required touching supervision for oral hygiene. Review of the plan of care dated 04/03/23 noted Resident #47 had an activity of daily living self-care deficit performance. Interventions included to monitor and document any changes and any potential for improvement, reasons for deficit, and or declines in function. No interventions were provided directing staff to assist Resident #24 with oral hygiene. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to arrange for transportation to outside medical appointments. This affected one (Resident #46) resident out of three residents reviewed for transportation to outside appointments. The facility census was 73. Findings include: Resident #46 was admitted on [DATE] with diagnosis of multiple sclerosis, neuromuscular dysfunction of bladder and morbid obesity. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact and was dependent on one staff person for completing activities of daily. Further review of Resident #46's medical record revealed that Resident #46 had an outside appointment on 01/09/25 at 8:55 A.M. at a local hospital with a plastic surgeon for wound care services. No evidence was present in the medical record that Resident #46 attended her scheduled appointment on 01/09/25. The medical record also noted that Resident #46 attended another outside wound care appointment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure medications were properly secured. This affected two residents (#11 and #52) of six residents observed for medication administration. The facility census was 73. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 10/13/23. Diagnoses included chronic obstructive pulmonary disease, bi-polar disorder, schizoaffective disorder, type two diabetes, dementia with behavioral disturbance, and depressive disorder. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] noted Resident #11 had intact cognition. Observation on 02/09/25 at 10:24 A.M. noted medications located in a medication cup on Resident #11's bedside table. Interview during the observation, Resident #11 stated I didn't take my medications yet. Interview on 02/09/25 at 10:27 A.M. with Unit Manager #103 verified the resident's medications were left at the bedside. Interview on 02/09/25 on 02/09/25 at 10:30 A.M.,…

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

Based on observation and interview, the facility failed to ensure residents had a functional call light. This affected one (Resident #46) of 25 sampled residents. The facility census was 75. Findings include: Observation and interview on 02/09/25 at 10:25 A.M. with Resident #46 revealed that it can take hours for her call light to be answered. Resident #46 pressed her call light at 10:37 A.M. the visual light outside Resident #46's room indicating Resident #46 call light was activated was not illuminated to alert staff she required assistance. Observation and interview on 02/09/25 at 10:46 A.M. with Certified Nursing Assistant (CNA) #192 confirmed that Resident #46's call light outside her door was not working.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff approved to drive the facility bus were appropriately trained on safety mechanisms in the facility bus upon hire and annually. This affected one resident (#24) of three residents reviewed for accidents. The facility census was 73. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/19/22 with diagnoses including chronic obstructive pulmonary disease, unspecified, muscle wasting and atrophy, major depressive disorder, and other lack of coordination. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] noted Resident #24 had intact cognition. The assessment revealed Resident #24 required maximum (staff) assistance for activities of daily living and utilized an electric wheelchair for mobility. Review of the undated plan of care revealed Resident #24 was at risk for falls and had an activity of daily living self-care deficit. Review of nurse progress notes 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 observation, interview, record review and facility policy review, the facility failed to ensure oxygen tubing was changed as ordered for residents #21 and #40. This affected two residents (#21 and #40) of four residents observed for respiratory care. The facility census was 66. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 03/23/23 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. Review of the care plan dated 11/01/24 revealed Resident #21 had alterations in respiratory function related to COPD. An intervention included administer oxygen as ordered. Review of the physician orders for November 2024 revealed Resident #21 had an order to change oxygen tubing every Sunday on night shift. Observation on 11/21/24 at 11:11 A.M. revealed Resident #21 was in bed and was wearing oxygen via a nasal cannula. Further observation revealed the oxygen…

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 therapeutic diets were provided as ordered by the physician for Residents #25 and #39. This affected two residents (#25 and #39) of four residents observed for therapeutic diets. The facility census was 66. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 04/14/22. Diagnoses included dementia and cognitive deficits. Review of the care plan dated 10/02/24 revealed Resident #25 had nutritional problems. Interventions included providing/serving the diet as ordered. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. Review of the physician orders for November 2024 revealed Resident #25 had an order for a mechanical soft diet with ground meats. Observation on 11/21/24 at 7:52 A.M. revealed Resident #25's breakfast consisted of scrambled eggs, a blueberry muffin, and two strips of whole bacon. The observation of Resident #25's meal ticket…

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

Based on observation and interview, the facility failed to ensure crash carts contained the appropriate supplies. This had the potential to affect all residents residing in the facility. The facility census was 66. Findings include: Interview on 11/21/24 at 8:10 A.M. with Licensed Practical Nurse (LPN) #259 revealed the memory care unit did not have a crash cart. LPN #259 stated there was a crash cart located outside of the unit; however, she was not aware if the crash cart had the appropriate equipment. Observation of the crash cart with LPN #255 on 11/21/24 at 8:51 A.M. revealed there was no checklist of equipment. She stated she was not sure of all the required equipment that should be on the cart. Observation revealed the crash cart had an empty oxygen tank, no non-rebreather mask (oxygen mask that delivers a high concentration of oxygen) or blood pressure cuff. Observation of the crash cart on 11/25/24 at 11:30 A.M. with LPN #257 revealed no oxygen tank on the cart and no checklist of required supplies. LPN #257 stated there should have been an oxygen tank on the cart and…

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

Based on personnel record review, review of the Bureau of Criminal Investigation (BCI) log, review of the Ohio Board of Nursing's website and review of facility policy, the facility failed to ensure implementation of their abuse prevention policy related to pre-employment background checks. This had the potential to affect all 60 residents in the facility. The facility census was 60. Findings include: 1. Review of the personnel file for Minimum Data Set Coordinator (MDSC) #308 revealed a hire date of 10/03/23. Further review revealed revealed MDSC #308 disclosed on her employment application she had been convicted of a felony for conspiracy to commit mail fraud. Review of Ohio Board of Nursing's website revealed MDSC #308's Licensed Practical Nurse (LPN) license had board action taken against it as a result of a felony conviction for one count of conspiracy to commit mail fraud. MDSC #308's nursing license had permanent restrictions, including not working as a LPN for agencies providing in-home care, for hospice care programs providing in-home care, for staffing agencies or pools,…

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

Based on observation, staff interview, review of posted meal times and review of the dietary staff schedule, the facility failed to ensure sufficient dietary staff to provide resident meals in a timely manner. This affected all 60 residents in the facility. The facility census was 60. Findings include: Review of the facility posted meal times revealed lunch was to be served beginning at 11:30 A.M. Interview on 09/30/24 at 10:50 A.M. with Dietary Manager (DM) #302 revealed lunch tray line would begin at 11:30 A.M. Observation on 09/30/24 from 11:16 A.M. to 1:38 P.M. of the lunch tray line services revealed there was one dietary aide (DA) and DM #302 was the acting cook. Continuous observation revealed the lunch meal service began at 12:24 P.M., which was 54 minutes later than the posted meal time. The residents in the dining room applauded when the kitchen door was opened. Concurrent interview with DM #302 confirmed the lunch meal was served late. DM #302 said the kitchen ran later on Mondays because of staffing issues. DM #302 stated dietary staff who worked on the weekend had…

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

Based on observation and staff interview, the facility failed to serve food in a manner that was palatable and attractive. This had the potential to affect all 60 residents in the facility. The facility census was 60. Findings include: Observation on 09/30/24 from 11:16 A.M. to 1:38 P.M. of the lunch tray line revealed the chili con carne (soup) was served on a plate, including pureed meals, alongside rice and corn. The chili ran into the other food items on the plate. Concurrent interview Dietary Manager (DM) #302 verified the chili con carne was served on a plate rather than a bowl. DM #302 stated the bowls they had did not keep soups hot, further stating, with the chili on a plate, he could use a plate warmer and domed lid to keep it warm. DM #302 verified it was not appealing to look at and some residents might have issues with the chili spreading out over the plate and touching all the other food items. DM #302 said he would serve the chili in a bowl if he could figure out how to keep it hot. Interview on 10/01/24 at 10:30 A.M. with Registered Dietitian (RD) #452 revealed 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.

Based on observation, review of the dishwasher temperature logs and staff interview, the facility failed to maintain dishwasher water temperatures at the manufacturer's minimum water temperature during the wash cycle. This had the potential to affect all 60 residents in the facility. The facility census was 60. Findings include: Observation on 09/30/24 at 11:35 A.M. to 11:44 A.M. of the facility dishwasher revealed a manufacturer's label indicating the minimum water temperature for the wash cycle was 155 degrees Fahrenheit (F) Continued observation revealed the dishwasher water temperature did not meet the minimum wash cycle temperature of 155 degrees F after being run for three consecutive cycles. Concurrent interview with Dietary Aide (DA) #316 verified the dishwasher did not reach the minimum temperature for the wash cycle during the observation. Review of the dishwasher temperature logs with DA #316 also verified there were multiple days on the temperature log that were less than the required minimum wash temperature. DA #316 further stated it normally took multiple runs to get…

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 interview, medical record review, staff interview and review of facility policy, the facility failed to ensure smoking devices were secured. This affected one resident (#9) of one resident reviewed for smoking. Additionally, the facility failed to ensure thorough fall investigations were completed. This affected five residents (#20, #22, #38, #44 and #61) of five residents reviewed for falls. The facility census was 60. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 10/24/23. Diagnoses included vertebrae fracture, urinary tract infection, paraplegia, cannabis use and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/06/24 revealed Resident #9 was cognitively intact. He required setup assistance for eating and oral hygiene, supervision for toileting, partial to moderate assistance for personal hygiene and substantial or maximum assistance for showering. Resident #9 was a smoker. Review of the…

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

Based on observation, medical record review, review of the production meal sheet and staff interview, the facility failed to ensure all pureed food items identified on the menu were provided. This affected six residents (#6, #16, #23, #35, #37 and #44) of six residents identified by the facility as having orders for puree food texture. The facility census was 60. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/30/21 with diagnoses including dementia, hypertension and type two diabetes mellitus. Review of the nutrition care plan, revised 10/03/23, revealed Resident #6 had nutritional problems related to type two diabetes mellitus, hypertension, hyperlipidemia, dementia, hyperglycemia, therapeutic diet order, altered texture diet, poor blood sugar control, edentulous, weight fluctuations, diuretic therapy and need for supplement. Interventions included provide and serve diet as ordered, monitor and record meal intakes and consistent carbohydrate diet with puree texture. Review of the physician's orders for September 2024 revealed 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, resident interview, medical record review and staff interview, the facility failed to provide adaptive equipment during meals for nine residents (#41, #37, #16, #6, #58, #25, #2, #50, and #29) of nine residents identified by the facility who utilized adaptive equipment. The facility census was 60. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 03/21/22. Diagnoses included dementia, abnormal weight loss, need for assistance with personal care and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/20/24, revealed Resident #41 was rarely or never understood and required (staff) supervision or touch assistance with eating. Review of the care plan dated 03/21/23 revealed Resident #41 had a nutritional problem related to Dementia and abnormal weight loss. Observation on 09/25/24 at 12:04 P.M. revealed Licensed Practical Nurse (LPN) #456 was assisting Resident #41 with the lunch meal in the main dining…

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 facility self-reported incidents (SRI) and staff interview, the facility failed to ensure complete and accurate medical records. This affected five (#39, #49, #42, #25 and #55) of five residents reviewed for accurate medical records. The facility census was 60. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/10/15 with diagnoses including dementia, Alzheimer's disease and major depressive disorder. Further review of the medical record revealed Resident #39 had allergies to chicken and turkey. Review of the care plan, dated 10/26/17, revealed Resident #39 was allergic to chicken and turkey with interventions to document the allergy and notify all disciplines of the allergy, monitor for signs and symptoms of an allergic reaction, and relay the allergy if the resident transfers out of the facility. Interview on 10/03/24 at 10:42 A.M. with [NAME] President of Operations (VPO) #451 confirmed Resident #39 had documented…

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 personnel record review and staff interview, the facility failed to provide annual behavioral health/dementia education. This had the potential to affect 32 residents (#1, #4, #5, #6, #11, #12, #16, #18, #20, #22, #23, #26, #29, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43, #44, #46, #49, #53, #54, #55, #57 and #60) of 32 residents identified by the facility with a diagnosis of dementia. The facility census was 60. Findings include: Review of State Tested Nursing Assistant (STNA) #364's personnel record, with Regional Director of Operations (RDO) #450, revealed a hire date of 03/15/13. Further review revealed no evidence behavioral health/dementia education was completed in 2023 or 2024. Interview on 10/02/24 at 4:45 P.M. with STNA #364 confirmed she had not received any behavioral health/dementia training since 2021. Interview on 10/02/24 at 4:48 P.M. with RDO #450 verified the facility had no evidence that any staff had received behavioral health/dementia training since 2021. RDO #450 confirmed the facility had a dementia/behavior unit where residents with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to notify the physician of allegations of sexual abuse. This affected one resident (#42) of one resident reviewed for physician notification. The facility census was 60. Findings include: Record review for Resident #42 revealed an admission date of 12/06/23 and a readmission date of 08/22/24. Diagnoses included Wernicke's Encephalopathy (presence of neurological symptoms caused by biochemical lesions of the central nervous system) and post-traumatic stress disorder. Review of the admission Medicare Five-Day Minimum Data Set (MDS), dated [DATE], revealed Resident #42 was cognitively intact. Resident #42 had no impairment of the upper of lower extremities and used a walker/wheelchair for mobility. Review of SRI tracking number 249272, dated 07/02/24 at 2:53 P.M., revealed Resident #42 was the alleged perpetrator of a sexual abuse allegation against a female resident. Further review of Resident #42's medical record…

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, family interview, staff interview and medical record review, the facility failed to ensure a comfortable, homelike environment free from loud noises. This affected three residents (#42, #28 and #17) of three residents reviewed for a comfortable, homelike environment. The facility census was 60. Findings include: 1. Record review for Resident #42 revealed an admission date of 12/06/23 and a readmission date of 08/22/24. Diagnoses included Wernicke's Encephalopathy (presence of neurological symptoms caused by biochemical lesions of the central nervous system) and post-traumatic stress disorder. Review of the admission Medicare Five-Day Minimum Data Set (MDS) assessment, dated 08/28/24, revealed Resident #42 was cognitively intact. Review of the care plan initiated 03/24/24 revealed Resident #42 had an alteration in mood/behavior/psychosocial well-being related to anxiety. Interventions included attempt to identify what triggers behaviors, convey acceptance of resident, encourage resident to take an active role within the facility and introduce…

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 interview, medical record review, review of Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to ensure residents were free from abuse. This affected two residents (#25 and #55) of three residents reviewed for abuse. The facility census was 60. Findings include: 1. Record review for Resident #25 revealed an admission date of 10/19/23. Diagnoses included a history of cerebral infarction and hemiplegia with hemiparesis affecting the left non-dominant side. Further review of the medical record revealed Resident #25 was cognitively intact. 2. Record review for Resident #55 revealed an admission date of 10/13/23. Diagnoses included chronic obstructive pulmonary disease, neuromuscular dysfunction, anxiety disorder, macular degeneration, schizoaffective disorder and muscle weakness. Further review revealed Resident #55 was cognitively intact. Record review for Resident #42 revealed an admission date of 12/06/23 and a readmission date of 08/22/24.…

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, hospice staff interview and review of facility policy, the facility failed to ensure residents were free from misappropriation. This affected one resident (#57) of three residents reviewed for misappropriation, with the potential to affected three additional residents (#26, #36 and #44) who also received hospice services. The facility census was 60. Findings include: Record review for Resident #57 revealed an admission date of 02/01/24. Diagnosis included Alzheimer's disease and age-related debility. Further review revealed Resident #57 elected hospice benefits with a start date of 02/01/24. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57 was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. Interview on 09/25/24 at 11:54 A.M. with State Tested Nursing Assistant (STNA) #326 revealed staff Always run out of supplies. They are in 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.

Based on observation, resident interview, family interview, medical record review, staff interview and review of facility policy, the facility failed to ensure residents were free from physical restraints. This affected one resident (#42) of one resident reviewed for restraints. The facility census was 60. Findings include: Record review for Resident #42 revealed an admission date of 12/06/23. Diagnoses included Wernicke's Encephalopathy (presence of neurological symptoms caused by biochemical lesions of the central nervous system) and post-traumatic stress disorder. Review of the admission Medicare Five-Day Minimum Data Set (MDS) assessment, dated 08/28/24, revealed Resident #42 was cognitively intact. Resident #42 used a walker/wheelchair for mobility. Review of the care plan initiated 03/24/24 revealed Resident #42 had an alteration in mood/behavior/psychosocial well-being related to anxiety, mobility decline/deficit, unrealistic expectations and sexual tendencies. Interventions included attempting to identify what triggers behaviors, convey acceptance of resident, encourage…

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 staff interview, medical record review, review of Self-Reported Incidents (SRI), review of facility investigations and review of facility policy, the facility failed to accurately document and thoroughly investigate allegations of abuse. This affected three residents (#25, #55 and #49) of four residents reviewed for facility investigations. The facility census was 60. Findings include: 1. Record review for Resident #25 revealed an admission date of 10/19/23. Diagnoses included a history of cerebral infarction and hemiplegia with hemiparesis affecting the left non-dominant side. Further review revealed Resident #25 was cognitively intact. Review of SRI tracking number 249272, dated 07/02/24 at 2:53 P.M., revealed the facility received an allegation of sexual abuse involving Resident #42 and Resident #25. Resident #42 was placed on 15-minute checks at that time. Further review revealed Resident #42 was alleged to have asked Resident #25 for a gesture of sexual nature. The SRI did not specify what the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure care plans were updated when new interventions were implemented. This affected two residents (#22 and #38) of two residents reviewed for care planning. The facility census was 60. Findings include: 1. Review of the medical record for Resident #22 reveal an admission date of 01/29/24. Diagnoses included cerebral infarction, depression, neuropathy, heart disease, dementia and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/25/24, revealed Resident #22 was severely cognitively impaired. Resident #22 required set-up assistance for eating, substantial or maximum assistance for oral hygiene, toileting and showering and most dependent for personal hygiene. He had two falls since the previous assessment and was always incontinent of bowel and bladder. Review of the physician's orders for Resident #22 for October 2024 revealed an order for a sign to be in Resident #22's room to remind him to use his…

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, family interview, medical record review, review of shower schedules, review of shower/bath sheets, staff interview and review of facility policy, the facility failed to provide routine showers for residents dependent for care. This affected one resident (#46) of three residents reviewed for showers. The facility census was 60. Findings include: Review of Resident #46's medical record revealed an admission date of 06/21/23. Diagnoses included Alzheimer's disease, cognitive communication deficit and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/14/24, revealed Resident #46 was rarely or never understood. Resident #46 was (staff) dependent for all activities of daily living (ADLs), including bathing/showers. Review of the care plan dated 09/26/23 revealed Resident #46 had an ADL self-care performance deficit. Interventions included total assistance by staff for bathing/showering. Review of the shower schedule revealed Resident #46 was scheduled to receive showers on Wednesdays and Saturdays on second shift. Review of 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 resident interview, family interview, staff interview, medical record review, review of hospital documents and review of transportation service communication, the facility failed to ensure transportation was arranged for Resident #02's outside appointments. This affected one resident (#02) of two residents reviewed for transportation services. Additionally, the facility failed to ensure a physician ordered follow-up appointment was scheduled for Resident #42. This affected one resident (#42) of two residents reviewed for coordination of care. The facility census was 60. Findings include: 1. Record review for Resident #02 revealed an admission date of 10/11/18. Diagnoses included multiple sclerosis and neuromuscular dysfunction of the bladder. Review of the annual Minimum Data Set (MDS) assessment, dated 09/06/24, revealed Resident #02 was cognitively intact. Resident #02 had progressive neurological conditions, impairment to both sides of the lower extremities, was dependent for toileting and bed…

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

Based on observation and staff interview, the facility failed to provide food items free of listed allergens for Resident #2. This affected one resident (#2) and had the potential to affect five additional residents (#11, #30, #39, #47, and #57) identified by the facility as having food allergies. The facility census was 60. Findings include: Review of the medical record for Resident #2 revealed an admission date of 10/11/18 and a re-admission date of 02/03/23. Diagnoses included multiple sclerosis, osteomyelitis of the left shoulder, major depressive disorder and anxiety disorder. Further review of the medical record revealed Resident #2 had allergies to Prednisone, eggs and shellfish. Observation on 09/30/24 at 12:41 P.M. of the lunch tray line revealed Resident #2's tray ticket indicated an allergy to eggs. Further observation of Resident #2's tray revealed chocolate cake on the tray. Interview on 09/30/24 at 12:50 P.M. with Resident #2 confirmed she had an egg allergy and stated she did not always get what she was supposed to at meals. Interview on 09/30/24 at 12:55 P.M. with…

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

Based on observation, interview with fire marshall, review of diswasher temperature monitoring logs, review of the Food and Drug Administration (FDA) Food Code, and staff interview, the failed to maintain the range hood vents in a sanitary manner and failed to ensure the dishwasher washing temperature was maintained to properly sanitize the kitchen dishware, utensils and equipment. This had the potential to affect all the residents who ate their meals in the facility. The facility census was 69. Findings include: An interview with the Fire Marshall on 06/06/24 at 11:00 A.M. revealed she was in the facility for the fire safety inspection and wanted to alert the surveyor of the failure of the facility to maintain a clean and sanitary range hood in the kitchen. Observations during a tour of the kitchen on 06/06/24 at 11:16 A.M. revealed the range hood vents were coated with a thick layer of grease and debris. The range hood plaque, located on the outside of the hood cover, revealed the last time the range hood was cleaned was October 2023. The dishwasher was ran through two cycles with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of the facility policy, and review of the reference website Medscape.com, the facility failed to ensure staff administered medication with less than a five percent error rate. This affected one (#43) out of three residents observed for medication administration with a 8.69% error rate observed. The facility census was 69. Findings include: Review of the medical record revealed Resident #43 was admitted on [DATE]. Diagnoses included dementia, peripheral vascular disease, high blood pressure, obesity, schizophrenia, anxiety, hypothyroidism, and dysphagia. Resident #43's physician orders, dated 06/01/24 to 06/30/24, revealed to administer the following medications in the morning: calcium-Vitamin D-minerals oral tablet chewable 600-400 milligram (mg)-unit one tablet for supplement, cholecalciferol tablet 50 micrograms (mcg) one table orally for supplement, lisinopril one tablet 20 mg, metoprolol succinate 24 hour Extended Release (ER) one 50 mg tablet 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, staff interview, and review ofreview of the reference website Medscape.com, the facility failed to ensure medications were administered without a significant error. This affected one (#43) out of three residents observed during medication administration. The facility census was 69. Findings include: Observation of medication administration on 06/05/24 at 8:26 A.M. revealed Registered Nurse (RN) #273 administered medications to Resident #43. RN #273 administered calcium-vitamin D mineral 600-400 mg tablet, lisinopril 20 mg tablet, metoprolol succinate 50 mg extended release tablet, and trazadone hcl 25 mg tablet medications by placing the medications in a plastic envelope and crushing the medications using a pill crusher device. RN #273 then poured the crushed medications in a medication cup and added applesauce, mixed the crushed medications in applesauce, entered Resident #43's room and administered the medications to Resident #43. An interview with RN #273 on 06/05/24 at 8:44 A.M. verified she should not have crushed the metoprolol succinate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of facility policy, the facility failed to ensure staff adhered to infection control standards during colostomy care. This affected one (#27) out of three residents reviewed for colostomy care. The facility census was 69. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included aortic aneurysm, heart failure with cardiac pacemaker, Parkinson's disease, depression, anxiety, diabetes mellitus, high blood pressure, obesity, partial intestinal obstruction with colostomy, and anemia. A review of Resident #27's physician order dated 05/29/24 revealed to change the colostomy wafer and bag every three days, apply calmoseptine to peristoma area every Monday, Wednesday and Friday for ostomy care. Observation on 06/06/24 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #274 gathered the supplies needed to perform Resident #27's colostomy care. LPN #274 placed the supplies on Resident #27's bedside…

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, review of facility policy and interviews, the facility failed to ensure advanced directives were readily available and followed during a medical emergency for Resident #66. This affected one resident (Resident #66) of three residents reviewed for advance directives. The facility census was 64. Findings included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included heart failure, respiratory failure, atrial fibrillation, congestive heart failure, nonrheumatic aortic stenosis, atherosclerotic heart disease, cardiomyopathy, hypertension, major depressive disorder, transient ischemic attack, and thoracic aortic ectasia. Resident #66 expired in the facility on [DATE]. Review of the physician's orders revealed Resident #66 had an order for Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) dated [DATE]. Review of the DNR identification form revealed Resident #66 requested a code status of Do-Not-Resuscitate Comfort Care Arrest (DNRCCA). It…

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 notify the physician when Resident #65 was not administered routine insulin according to the physician order. This affected one resident ( Resident #65) of three reviewed for insulin administration. The facility census was 64. Findings included: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, cervical sprain, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, diabetes, absence of left breast, breast cancer, diverticulosis, dry eye syndrome, major depressive disorder, spinal stenosis, chronic migraines, bilateral cataracts, osteoarthritis of both knees, peripheral vascular disease, and protein calorie malnutrition. She was discharged on 03/15/24 with hospice services. Review of a physician order revealed Resident #65 had an order for 64 units of degludec insulin dated 02/14/24. She also had orders for the aspart…

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 did not ensure Resident #65 was administered insulin according to physician orders. This affected one resident ( Resident #65) of three residents reviewed for insulin administration. The facility census was 64. Findings include: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, cervical sprain, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, diabetes, absence of left breast, breast cancer, diverticulosis, dry eye syndrome, major depressive disorder, spinal stenosis, chronic migraines, bilateral cataracts, osteoarthritis of both knees, peripheral vascular disease, and protein calorie malnutrition. She was discharged on 03/15/24 with hospice services. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #65 had intact cognition. She received insulin. Review of a physician order revealed Resident #65 had an order…

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 document the death of Resident #66 in the medical record. This affected one resident ( Resident #66) of three reviewed for complete medical record. The facility census was 64. Finding included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included heart failure, respiratory failure, atrial fibrillation, congestive heart failure, nonrheumatic aortic stenosis, atherosclerotic heart disease, cardiomyopathy, hypertension, major depressive disorder, transient ischemic attack, and thoracic aortic ectasia. Further review of the medical record and of the progress notes for Resident #66 revealed no documentation of him expiring in the facility. The last health status note was dated [DATE] at 9:09 A.M. There was a psychiatric progress note dated [DATE]. Review of a document titled Code Blue Bedside Documentation dated [DATE] and the Emergency Medical Services run report 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 interview and personnel file review the facility failed to complete state tested nurse aide registry verification prior to allowing an individual to serve as a STNA. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Interview on [DATE] between 4:15 A.M. and 4:47 A.M. with State Tested Nursing Assistant (STNA) #237 and STNA #231 revealed Dietary Aide (DA) #251 worked as an STNA without having a current certification. Review of DA #251's personnel files revealed an employment application dated [DATE] indicating the position being applied for was that of an STNA. DA # 251's personnel file had an STNA certification with an expiration date of [DATE]. Interview on [DATE] at 4:36 P.M. with the Director of Nursing (DON) confirmed DA #251's personnel file contained an expired STNA certificate. The DON stated DA #251 was currently working in the kitchen as a kitchen aide. Interview on [DATE] with DA #251 revealed he had been employed at 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 interview, record review, staff statement review, police report review, and text message review the facility failed to ensure a nurse showing signs of potential impairment was evaluated to ensure she was competent to provide direct resident care and/or was removed from direct resident care following suspicions of impaired behaviors by co-workers. This had the potential to affect 32 residents (#17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63), who resided on the 300 and 400 units where the nurse was working. The facility census was 63. Findings include: Interview on 02/28/24 at 5:57 A.M. with State Tested Nursing Assistant (STNA) #236 revealed she worked on 02/17/24 from 11:00 P.M. until 12/18/24 at 7:00 A.M. During the shift, STNA #236 observed Registered Nurse (RN) #217 dancing in the halls, singing loudly and acting weird. STNA #236 stated it appeared that RN #217 may have been under 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 interview, record review, staff statement review, and text message review the administration failed to timely respond to reports of a nurse showing signs of potential impairment. This had the potential to affect 32 residents (#17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63), who resided on the 300 and 400 units where the nurse was working. The facility census was 63. Findings include: Interview on 02/28/24 at 5:57 A.M. with State Tested Nursing Assistant (STNA) #236 revealed she worked on 02/17/24 from 11:00 P.M. until 12/18/24 at 7:00 A.M. During the shift, STNA #236 observed Registered Nurse (RN) #217 dancing in the halls, singing loudly and acting weird. STNA #236 stated it appeared that RN #217 may have been under the influence of something. RN #217 was moving very fast and she observed RN #217 taking something out of the narcotic box and throwing it in the medication room. STNA #236…

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 and interview the facility failed to ensure incontinence care was provided in a timely manner. This affected one resident (#21) of three observed for incontinence care. The facility census was 63. Findings include: Review of Resident #21's medical records revealed an admission date of 11/30/21. Diagnoses included dementia and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition and was incontinent of bowel and bladder. Review of the care plan dated 02/21/24 revealed Resident #21 was incontinent of bowel and bladder. Interventions included clean peri-area after each incontinence episode. Interviews on 02/28/24 from 4:15 A.M. to 4:47 A.M. with State Tested Nursing Assistant (STNA) #237 and STNA #231 revealed they observed residents who appeared to have been soiled in urine and feces for long periods of time. Observation of incontinence care on 03/04/24 at 9:15 A.M. with STNA #244 for Resident #21 revealed Resident #21 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure all parties were notified Resident #75's change of condition. This affected one resident (#75) of three residents reviewed for notification. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. Review of the fall incident report dated 12/19/23 at 2:00 P.M. Resident #75 was found on the floor between the wall and bed. No injury was noted at the time of the fall. Resident #75 was sent to hospital for evaluation. There was no documented evidence of family notification of the fall and transfer to the hospital. Interview on 02/12/24 at 11:01 A.M. with the Director of Nursing (DON) verified the agency nurse told her she was going to notify the family of the fall. She stated she went to a meeting after Resident #75 left the facility. The DON stated she 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 interview and record review the facility failed to provide an environment that was free from accident hazards. This affected one resident (#75) of three residents reviewed for accidents. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. Review of the plan of care dated 01/12/23 revealed Resident #75 was at risk for falls related to impaired balance, history of falls and intentionally climbs out of bed. Interventions included assisting and encouraging the resident to go to common areas when awake, for safety, assuring bed is locked, defined perimeter mattress, floor mat to left side of bed while in bed, and bed in low position. Review of the fall risk assessment dated [DATE] revealed Resident #75 was at high risk for falls. Review of the fall incident report dated 12/19/23 at 2:00 P.M. Resident #75 was found on the floor between the wall…

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 facility policy review the facility failed to ensure all residents with special dietary needs were given appropriate meals. This affected one resident (#75) of three residents reviewed for allergies. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. The resident was allergic to shellfish. Review of the employee memorandum dated 12/20/23 revealed [NAME] #300 was given an oral warning for serving shellfish to a resident with allergies. Date of violation was 12/15/23. Resident #75 was served crab cakes despite the meal ticket stating allergy in multiply spots on the ticket. The corrective action was for [NAME] #300 to take caution when serving food and to look at meal tickets for allergies before sending the tray out of the kitchen. Review of the concern log for November, December and January revealed on 12/21/23 Resident #75 received shellfish when he had a shellfish allergy.…

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 fall interventions were in place for Resident #20. This affected one resident (#20) out of three residents reviewed for falls. The facility census was 61. Findings include: Review of the medical record for Resident #20 revealed an admission date of 02/28/18 with medical diagnoses including non-Hodgkin lymphoma, vitamin d deficiency, chronic venous hypertension with ulcer of unspecified lower extremity, repeated falls, major depressive disorder, muscle weakness, disorder of muscle, and unspecified abnormalities of gait and mobility. Review of Resident #20's care plan dated 06/05/18 revealed the resident was at risk for falls as evidence by diagnosis of repeated falls and received medications that can increase fall risk. Resident #20's fall interventions included footwear per orders, assess skin every shift for three days for any bruising or bleeding after fall and report abnormalities to the physician, keep call light in easy reach at all times and answer promptly, keep frequently used items within…

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, resident council minute review, and observation of a test tray, the facility failed to serve food that was palatable. This had the potential to affect all 59 residents, The facility census was 59. Findings include: Interview on 12/04/23 from 3:26 P.M. through 12/05/23 at 5:00 P.M., with Residents #09, #51, #23, #24, #18, #32, #3, #45, #27, #26, and #29 revealed the food did not taste good, was not palatable. Observation on 12/05/23 at 11:40 A.M., revealed [NAME] #234 plated residents food. The menu consisted of rigatoni with meat sauce, green beans, dinner roll, and mandarin oranges. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the 200-hall food cart, the last food cart to be served. Observation on 12/05/23 at 12:12 P.M., was made as the test tray was delivered to the 200 hall. The test tray remained on the cart in view of the surveyor, until all other trays were distributed…

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 interview, staff interview, medical record review, and review of the policy, the facility failed to store medications in a safe manner. This had the potential to affect three (#09, #49 and #59) and the potential to affect four (#66, #58, #52, and #26) additional residents who were cognitively impaired and independently mobile. The facility census was 59. Findings include: 1. Record review for Resident #09 revealed an admission date of 10/24/23. Diagnosis included pressure ulcer of the sacral region stage three, neuromuscular dysfunction of the bladder, local infection of the skin and subcutaneous tissue, paraplegia, and stable burst fracture of the fourth thoracic vertebra subsequent encounter for fracture with routine healing. Interview and observation on 12/04/23 at 10:35 A.M., with Resident #09 revealed the resident was lying in bed. At the foot of the bed was a blister pack of loperamide (anti-diarrheal) two milligram (mg) capsules. There were 18 of 30 loperamide remaining in…

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

Based on observation and staff interview, the facility failed to serve safe food products to residents. This had the potential to affect 48 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #19, #20, #21, #22, #23, #25, #28, #30, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43, #44, #45, #47, #48, #50, #51, #53, #54, #55, #56, #57, and #60) of 59 residents served from the kitchen. The facility census was 59. Findings include: Observation on 12/05/23 at 11:40 A.M., revealed [NAME] #234 was plating food. The menu consisted of rigatoni with meat sauce, green beans, dinner roll, and mandarin oranges. Observation revealed the plates were heated and the food was at the appropriate temperature. Observation revealed the dinner rolls were taken directly from the plastic bag they were delivered in. Observation revealed while [NAME] #234 grabbed a dinner roll from the bag and placed it on the plate, the roll was placed upside down. Observation revealed the entire corner of the roll was green with black spotted areas on the bottom. [NAME] #234 revealed she…

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

Based on observation and staff interview, the facility failed to maintain infection control practices while passing the lunch trays. This affected 11 (17, #18, #27, #49, #52, #26, #58, #29, #5, #15 and #39) of 11 resident that staff assisted lunch trays. The facility census was 59. Findings include: Observation on 12/05/23 at 12:15 P.M., of tray pass on the 200 hall with [NAME] President of Clinical Operations #318 revealed State Tested Nursing Assistant (STNA) #258 passed eight residents lunch trays, Resident #17, #18, #27, #49, #52, #26, #58, and #29. Observation revealed STNA #258 did not use hand sanitizer or wash her hands while passing and setting up the eight resident lunch trays. STNA #258 verified she did not wash or sanitize her hands while passing and setting up the eight resident lunch trays. STNA #258 revealed she was not aware she was supposed to wash her hands or use hand sanitizer while passing trays. [NAME] President of Clinical Operations #318 confirmed STNA #258 passed eight residents lunch trays, assisted the residents with setting the trays up and did not wash…

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, review of resident council minutes, review of the Self-Reported Incident (SRI), and review of the policy, the facility failed to ensure an allegation of physical abuse/mistreatment was reported to the state agency as required. This affected one (#14) of three residents reviewed for staff treating residents with dignity and respect. The facility census was 59. Findings include: Review of Resident #14's medical record revealed an admission on [DATE]. Diagnosis included chronic atrial fibrillation, repeated falls, and difficulty in walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Resident #14 required extensive assistants of one with bed mobility, transfers, locomotion, and one-person physical assist with personal hygiene. Resident #14 used a wheelchair. Resident #14 was always incontinent of urine and always continent of bowel. Review of the care plan dated 09/04/23 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 medical record review, resident interview, staff interview, review of resident council minutes, review of the Self-Reported Incident (SRI), and review of the policy, the facility failed to ensure an allegation of physical abuse/mistreatment was investigated as required. This affected one (#14) of three residents reviewed for staff treating residents with dignity and respect. The facility census was 59. Findings include: Review of Resident #14's medical record revealed an admission on [DATE]. Diagnosis included chronic atrial fibrillation, repeated falls, and difficulty in walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Resident #14 required extensive assistants of one with bed mobility, transfers, locomotion, and one-person physical assist with personal hygiene. Resident #14 used a wheelchair. Resident #14 was always incontinent of urine and always continent of bowel. Review of the care plan dated 09/04/23 for Resident #14…

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, interview, and review of the policy, the facility failed to ensure upon discharge to home, the resident's medications were returned to the resident. This affected one (#62) of three residents reviewed for discharge. The facility census was 59. Findings revealed: Review for Resident #62's medical record revealed an admission date of 06/17/23 and a discharge date of 07/01/23. Review of the discharge summary for Resident #62 dated 07/01/23 at 3:38 P.M., completed by Registered Nurse (RN) #296 revealed Resident #62 left the facility at 2:20 P.M., with his wife and daughter, medications returned to wife, drug summary given and signed. Left in private vehicle. Review of the Prescription History provided by the facility pharmacy dated 12/11/23, revealed Resident #62 had eight medications, a 30-day supply of each, that were dispensed from the pharmacy to the facility on [DATE]. Record review revealed after Resident #62's discharge on [DATE], the remainder of the eight medications were…

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 record review, the facility failed to ensure a resident with a catheter had a care plan to address the care and treatment of the catheter to prevent infections. This affected one (#09) of three residents reviewed for care plans. The facility census was 59. Findings include: Record review for Resident #09 revealed an admission date of 10/24/23. Diagnosis included neuromuscular dysfunction of the bladder and paraplegia. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #09 was cognitively intact. Resident #09 had impairment on both sides of lower extremities. Resident #09 required substantial/maximum assist with toileting, bathing, personal hygiene, supervision with bed mobility, and partial moderate assist with transfers. Resident #09 used a wheelchair. Resident #09 had an external (Texas) catheter and was always incontinent of bowel. Review of the History and Physical for Resident #9 dated 10/25/23 completed by Primary Care…

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 medication Hydrofera Blue Wound Dressing user guide, the facility failed to provide wound care treatments per the physicians orders. This affected two (#09 and #03) of three residents reviewed for wound care. The facility census was 59. Findings include: 1. Review of Resident #09's medical record revealed an admission date of 10/24/23. Diagnosis included neuromuscular dysfunction of the bladder and paraplegia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact. Resident #09 had impairment on both sides of lower extremities. Resident #09 required substantial/maximum assist with toileting, bathing, personal hygiene, supervision with bed mobility, and partial moderate assist with transfers. Resident #09 had one stage three pressure ulcer over a bony prominence that was present on admission. Resident #09 was at risk for pressure ulcers. Resident #9 had a pressure reducing…

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 interview, staff interview, medical record review, and review of medication Hydrofera Blue Wound Dressing user guide, the facility failed to ensure staff was trained to provide wound care treatments per the physicians orders. This affected two (#09 and #03) of three residents reviewed for wound care. The facility census was 59. Findings include: 1. Review of Resident #09's medical record revealed an admission date of 10/24/23. Diagnosis included neuromuscular dysfunction of the bladder and paraplegia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact. Resident #09 had impairment on both sides of lower extremities. Resident #09 was at risk for pressure ulcers. Resident #9 had a pressure reducing device in his chair and bed. Resident #09 received pressure injury care. Record review of the weekly wound report dated 10/24/23, untimed, completed by assistant Director of Nursing (ADON)/Wound Care Nurse/Licensed Practical…

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

Based on interview and record review the facility failed to ensure State Tested Nursing Assistant's (STNA)'s #221, #231 #227 had annual performance evaluations. This affected three STNA's (#221, #231, and #227) out of four STNA's reviewed for performance evaluations and had the potential to affect all 68 residents in the facility. Findings include: Review of State Tested Nursing Assistant's #221, #227, and #231 personnel files revealed annual performance evaluations were not completed and placed in the files. Interview on 04/24/23 at 3:06 P.M. of Business Office Manager/Payroll/Human Resource (BOM/P/HR) #220 revealed performance evaluations were not completed for employees. BOM/P/HR #220 stated she had worked in the facility about a year and a half and evaluations had not been done since she was hired. BOM/P/HR #220 stated one of the reasons was probably because there was a high turnover rate of the Director of Nursing (DON). BOM/P/HR #220 stated she gave lists of employees that needed evaluations to the Director of Nursing, but they were not done, and there had been about four…

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

Based on observation and interview, the facility failed to ensure food was stored and served in a clean sanitary manner, and failed to ensure all food was dated and labeled properly. This had the potential to affect all 68 residents who received food from the kitchen. Findings include: 1. Initial tour of the kitchen occurred on 04/17/23 at 7:30 P.M. with the acting Dietary Manager #222. He further stated he has been acting director off and on for over two years. Review of the two stand up refrigerators on the side wall of the kitchen across from the prep counter revealed a tray of juice with 8 juice drinks in cups with lids on them. The tray nor the cups had a date on it showing the date they were poured and or put in the refrigerator. There was a plastic container on the bottom shelf with fruit punch in it that was half full that did not have a date on it as to the date it was made. There was a plastic container with cheese slices in it that was not dated as to when they were placed into this plastic container and placed into the refrigerator. There was a large jar of pickles that…

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

Based on interview and record review, the facility failed to ensure annual and 90 day performance evaluations were completed for Director of Nursing, Licensed Practical Nurse #206, Receptionist #228, and Housekeeper #264. This had the potential to affect all 68 residents in the facility. Findings include: Review of personnel records for the Director of Nursing, Licensed Practical Nurse (LPN) #206, Receptionist #228, and Housekeeper #264 revealed there were no 90 day or annual performance evaluations in the records. Interview on 04/24/23 at 3:06 P.M. of Business Office Manager/Payroll/Human Resource (BOM/P/HR) #220 revealed performance evaluations were not completed for employees. BOM/P/HR #220 stated she had worked in the facility about a year and a half and evaluations had not been done since she was hired. BOM/P/HR #220 stated one of the reasons was probably because there was a high turnover rate of the Director of Nursing (DON). BOM/P/HR #220 stated she gave lists of employees that needed evaluations to the Director of Nursing, but they were not done, and there had been about…

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 review of facility policy, the facility failed to ensure Resident #1's antipsychotic medication was reviewed per pharmacy recommendations to reduce the dose and the facility failed to ensure Resident's #1, #13, #32, #44 and #63 who were administered antipsychotic medications were monitored for side effects. This affected five residents (Resident's #1, #13, #32, #44, and #63) out of five reviewed for antipsychotic medications. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 10/28/22 and diagnoses included congestive heart failure, type two diabetes mellitus, and Alzheimer's Disease. Review of Resident #1's physician orders dated 10/28/22 revealed Fluoxetine Hydrochloride capsule 40 mg (Prozac), give one capsule by mouth one time a day for depression. Review of Resident #1's care plan dated 02/08/23, included Resident #1 used antidepressant medication and would be free from discomfort or adverse reactions related 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.

Based on interview and chart review, the facility failed to ensure the power of attorney (POA) or the next of kin of a resident was contacted regarding a change in the resident. This affected one resident (Resident #28) out of three residents reviewed for notification of change. Findings include: Resident #28 was admitted to this facility on 12/10/20. Her admitting diagnoses included low back pain, hemorrhoids, psoriasis, atrial fibrillation, cervical dysplasia, bipolar disorder, fibromyalgia, major depressive disorder and hypertension to name a few. Review of Resident #28's Minimum Data Set (MDS) 3.0 dated 02/03/23 revealed this resident was rarely understood due to dysphagia. The resident had a memory problem. Functionally, this resident needed supervision with set up only for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of this Resident's progress notes dated 01/30/23, revealed this resident slid from bed and landed on knees next to her recliner. Right elbow slightly red, resident moved it without facial grimacing or stating pain. A male resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #24's catheter care plan intervention was implemented and followed by the nursing staff. This affected one resident (Resident #24) out of three residents reviewed for implementation of care plan interventions. Findings include: Resident #24 was admitted to this facility on 02/22/23. His admitting diagnoses included paraplegia, encephalopathy, hypoglycemia, osteomyelitis of the vertebrae, and sacro region, Stage IV pressure ulcer in sacral region and inflammatory reaction due to indwelling urethral catheter. Review of Resident #24's Minimum Data Set Assessment (MDS) dated [DATE] revealed this resident was cognitively intact. Functionally, he needed supervision of one person for bed mobility and transfers. He needed limited assistance of one person for dressing and he needed extensive assistance of one person for toileting and personal hygiene. Review of Resident #24's plan of care dated 03/07/23 revealed the resident had a suprapubic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan meetings were held with the resident and/or the family. This affected two (Resident #28 and Resident #39) out of three residents reviewed for plan of care meetings. Findings include: 1. Resident #28 was admitted to this facility on 12/10/20. Her admitting diagnoses included low back pain, hemorrhoids, atrial fibrillation, bipolar disorder, major depressive disorder and irritable bowel syndrome to name of few. Review of Resident #28's Minimum Data Set Assessment (MDS) dated [DATE] revealed this resident was rarely understood due to dysphagia. She was noted to have a memory problem. Functionally, this resident needed needed set up only for bed mobility, transfers, dressing, toileting and personal hygiene. Review of this resident's progress noted from January 2023 to present revealed no progress note regarding plan of care meetings. The Regional Director of Clinical operations was asked on 04/18/23 to provide a copy of the care plan…

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, observation, and record review, the facility failed to ensure high blood glucose levels were properly addressed for Resident #16. This affected one resident Resident #16) out three residents reviewed for insulin. Findings include: Resident #16 was admitted to this facility on 08/03/22. Her admitting diagnoses included type II diabetes, hypothyroidism, psychosis due to a substance, major depressive disorder, insomnia, cirrhosis of the liver and hypertension. Review of this resident's Minimum Data Set Assessment (MDS) dated [DATE] revealed this resident was cognitively intact with a Brief Mental Status score of 15. Functionally, this resident needed the supervision of two people for bed mobility. She needed limited assistance of one for transfers and dressing, and she need extensive assistance of one person for toileting and personal hygiene. Review of this resident's physician orders date from January 2023 to present showed orders for: • Insulin regular Human solution 500 units/ml inject 85…

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 review of facility policy, the facility failed to ensure Resident #10's red and purple colored pressure injury to the right buttock and sacral area was assessed, monitored, and treated timely. This affected one resident (Resident #10) out of three residents reviewed for pressure ulcer injury. Findings include: Review of Resident #10's medical record revealed an admission date of 02/17/23 and diagnoses included aftercare following joint replacement surgery, multiple sclerosis and retention of urine. Review of Resident #10's care plan dated 02/20/23 included Resident #10 had the potential for impairment to the skin integrity related to fragile skin. Resident #10 would maintain or develop clean and intact skin by the review date. Interventions included to follow facility protocols for treatment of injury; to monitor, document, location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etcetera…

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 review of facility policy the facility failed to ensure incontinence care for Resident #40 was provided timely, and failed to ensure Resident #10's urinary tract infection was treated timely. This affected two residents (Resident's #10 and #40) out of three residents reviewed for incontinence care and urinary tract infections. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 02/17/23 and diagnoses included aftercare following joint replacement surgery, multiple sclerosis and retention of urine. Review of Resident #10's care plan dated 02/20/23 included Resident #10 had a urinary tract infection and a history of urinary tract infections. Resident #10's urinary tract infection would resolve without complications by the review date. Interventions included to give antibiotic therapy as ordered and monitor and document for side effects and effectiveness; monitor and document, report to the physician as needed signs 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, interview, record review and review of the facility policy the facility failed to ensure Resident's #1, #17 and #39 oxygen orders specified the oxygen flow to be administered in number of liters per minute and failed to specify how often oxygen saturations should be checked. This affected three residents (Resident's #1, #17 and #39) out of four residents reviewed for oxygen administration. The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 10/28/22 and diagnoses included congestive heart failure, type two diabetes mellitus, and Alzheimer's Disease. Review of Resident #1's physician orders dated 10/28/22, revealed as needed oxygen for complaints of shortness of breath, notify physician if oxygen saturations were less than 92 percent as needed. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #1 had severe cognitive impairment. Resident #1 required limited assistance 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 interview, observation, record review and Centers for Disease Control (CDC) guidance, the facility failed to ensure Resident #12 and #16 were cared for under proper infection control precautions. This affected two residents (Resident #12 and Resident #16) out of five residents reviewed for infection control. Findings include: 1. Review of the open medical record of Resident #16 revealed this resident was admitted on [DATE]. Her admitting diagnoses included type II diabetes, Hypothyroidism, psychosis due to a substance, major depressive disorder, cirrhosis of the liver and hypertension;. Review of Resident #16's Minimum Data Set Assessment (MDS) dated [DATE] revealed this resident was cognitively intact. She needed the supervision of two people for bed mobility, limited assistance of one person for transfers and dressing and extensive assistance of one person for toileting and personal hygiene. Review of Resident #16's urine analysis and culture and sensitivity reported on 04/11/23 revealed 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.

Based on observation and interview, the facility failed to ensure resident rooms were free from insects and maintained in a clean functioning manner This affected three residents (Resident #25, Resident #39 and Resident #59) out of three residents reviewed for physical environment. Findings include: Observation of facility on 04/18/23 at 9:30 A.M. to 10:06 A.M. with the Regional Director of Clinical Operations (RDCO) #260 revealed Resident #59's room was noted to have ants in her room by the side wall across from her her closet, under her bedside table and under her bed. Further review of this rooms revealed the two overhead bed lights were dim and there was not enough light in the room for the resident and lastly her toilet seat that was screwed onto the toilet was crooked and off center. Interview with the Resident #59 on 04/18/23 at 10:00 A.M. reiterated her toilet seat makes her feel like she is going to fall off since it is not in the center of the toilet. She further revealed she has complained to staff last week of the ants in her room and nothing has been done. She also…

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 and facility policy review the facility failed to ensure comprehensive policy and procedures were developed and implemented for the antibiotic stewardship program. This had the potential to affect all 58 residents residing in the facility. The census was 58. Findings include: Interview on 02/11/20 at 11:09 A.M. License Practical Nurse (LPN) # 73 revealed the Administrator and the Director of Nursing developed the policies and procedures for the facility. Interview on 02/11/20 at 11:18 A.M. with the LPN #74 verified the policy and procedures were developed and implemented by the Administrator and the DON and the policies were to be kept short without extra information. Interview 02/12/20 at 1:35 P.M. with the Director of Nursing (DON) verified the antibiotic stewardship policy did not have the necessary information to follow the program. Review of facility policy titled Antibiotic Stewardship Policy and Procedures, dated 09/2019, revealed it is the facilities to implement an Antibiotic Stewardship Program (ASP) which will promote the appropriate use 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 and staff interview the facility failed to ensure intravenous solutions were not expired. This had to potential to affect 58 residents residing at the facility. The facility was 58. Finding Include: Observation on [DATE] at 1:30 P.M. of the main medication room with License Practical Nurse (LPN) #92 revealed the following expired intravenous solutions: One-liter bag of Dextrose 5% in water (D5W) expired [DATE] Three bags 50 milliliter (mls) of sodium chloride 0/9% in water expired [DATE] Two 500 mls bags of sodium chloride 0.9% in water expired [DATE]. Interview with LPN #92 at 1:35 P.M. verified the above finding.

Based on observation, staff interview, and review of the facility policy and procedure, the facility failed to ensure an anchoring device to attempt to prevent accidental trauma, pain or injury from excessive tension or removal of a Foley catheter was in place for one resident This affected one Resident (#22) of one reviewed for catheter care. The facility census was 58. Findings include: Review of Resident #22's medical record with an admission date of 03/30/18. Diagnoses included neurogenic bladder and peripheral vascular disease. Observation on 02/12/20 9:42 A.M. of catheter care with State Tested Nurse Aides (STNA) #40 revealed Resident #22 had a leg device around her leg. The device did not have the Foley tubing attached with the tubing hanging free from the device. Interview on 02/12/20 at 9:44 A.M. with STNA #40 revealed the Foley catheter tubing was to be attached to the leg device to prevent the tubing from being pulled out. STNA # 40 verified the tubing was not secured to the leg device. Interview on 02/12/20 at 9:48 A.M. with Resident #22 revealed the catheter was changed…

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 the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected two Residents (Residents#15 and #54) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: 1. Resident #54's medical record revealed an admission date of 06/08/17 with diagnoses including Major depression disorder, vascular dementia and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/08/20, revealed the resident had impaired cognition, minimal depression, trouble concentrating on things, had feeling of being tired, behavioral symptoms directed towards others and was taking an antidepressant medication. Review of the monthly pharmacy recommendations to the attending physician dated 12/09/19, revealed the pharmacist made a recommendation to evaluate Lexapro 10 milligram (mg) for a gradual dose reduction. The physician addressed the pharmacist recommendations to decrease…

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 as needed medication orders for psychotropic drugs were limited to 14 days. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The facility census was 58. Finding Include: Review of Resident #7's medical record revealed an admission date of 03/08/19 with diagnoses including major depression, anxiety and heart failure. The quarterly Minimum Data Set (MDS) 3.0 dated 10/24/19 revealed the resident was cognitively intact, had mild depression, was verbal behavior towards other, had pain medication prescribed as needed (PRN). The medical record was absent of any documented reason to extend the use of as needed Xanax medication beyond 14 days. Review of the physician order dated 02/01/19 revealed the resident was to receive Xanax 0.5 milligram (mg) every 8 hours PRN for anxiety. The stop date for 180 days. Review of the monthly Pharmacy Recommendation to the Physician dated 01/01/10 through 02/12/20 revealed no recommendations to discontinue or reorder the PRN Xanax per guidelines.…

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 policy review and interview the facility also failed to ensure the Legionella policy had quality measures with specified testing protocols. This had the potential to affect all 58 residents currently residing in the facility. The facility census was 58. Finding Include: Review of the facility's policy titled Sanctuary Health Network Water Management Plan, undated revealed quality control measures for testing that included to monitor and log hot water temperatures, change aerators and shower wands when scale build-up becomes evident, flush fixtures weekly in areas not used often. The policy lacked acceptable ranges for control measures and corrective actions taken when control limits are not maintained. Interview on 02/10/10:30 A.M. with Corporate Maintenance #93 verified the Legionella policy lacked the quality control measures and protocols for specified testing.