Otterbein Monclova

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to ensure interventions were in place to promote healing of pressure ulcers. This affected two residents (#8 and #11) of four residents (#8, #10, #11, and #30) reviewed for pressure ulcers. The facility census was 54. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/15/25 with diagnoses including stage four sacral pressure ulcer, multiple sclerosis (MS), type two diabetes mellitus (DM2), paraplegia, depression, gastro-esophageal reflux disease (GERD), colostomy, neuromuscular dysfunction of bladder, insomnia, anemia, hypertension (HTN), hyperlipidemia, chronic pain syndrome, morbid obesity, non-pressure chronic ulcer of part of left lower leg with unspecified severity, non-pressure chronic ulcer of right ankle with unspecified severity, non-pressure chronic ulcer of buttock with unspecified severity, bullous pemphigoid, urinary…

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, and staff interview, the facility failed to ensure devices to prevent contractures were applied in accordance with physician orders. This affected one resident (#53) reviewed for the application of range of motion interventions. The facility census was 54. Findings include: Resident #53 admitted to the facility on [DATE] with the diagnoses including, cerebral infarction, type 2 diabetes mellitus, expressive language disorder, gastrostomy, and hypertension. According to the most current minimum data set assessment dated [DATE] noted Resident #53 assessed with severe cognitive impairment, limitation in range of motion to one side upper and lower extremity, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, receives all nutrition via feeding tube, at risk for pressure ulcer development with no current skin breakdown. On 03/02/25 a physician order was initiated for the application of a right hand splint to be on during…

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, observation, resident interview, staff interview, and policy review, the facility failed to ensure medications were secured and not left at the bedside. This affected one (#19) of seven residents reviewed for medications and had the potential to affect two residents the facility identified as cognitively impaired and independently mobile. The facility census was 54. Findings include: Review of the medical record for Resident #19 revealed an admission date of 06/21/24. Diagnoses included dysphagia following cerebrovascular disease, heart failure, chronic respiratory failure, chronic kidney disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required substantial/maximal assistance with eating. Review of the malnutrition risk care plan last revised 02/14/25 revealed to provide one to one supervision with meals/snacks/fluids. Review of a physician order dated 03/24/25 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, staff interview, resident interview, and review of a skills procedure, the facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and failed to ensure catheter tubing was secured. This affected one (#48) of two residents reviewed for urinary catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 54. Findings include: Review of the medical record for Resident #48 revealed an admission date of 02/13/25. Diagnoses included acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent for toileting hygiene and occasionally incontinent of bowel and bladder. The resident had an indwelling urinary catheter. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, staff interview, review of facility skills checklist and policy review, the facility failed to ensure infection control standards were in place. This affected one (#48) of two residents reviewed for indwelling catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 54. Findings include: Review of the medical record for Resident #48 revealed an admission date of 02/13/25. Diagnoses included acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent for toileting hygiene and occasionally incontinent of bowel and bladder. The resident had an indwelling urinary catheter. Review of the physician orders dated 02/14/25 revealed the resident had a 16 French urinary…

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 facility electronic medical record (EMR), resident interview, and staff interview, the facility failed to provide a sanitary and comfortable environment. This affected two (#33 and #212) residents of five (#11, #18, #33, #35, and #212) residents reviewed for environment. The facility census was 54. Findings include: 1. Review of the EMR for resident #33 revealed an admission date of 06/12/22 with diagnoses including congestive heart failure (CHF), type two diabetes mellitus (DM2), hypertension (HTN), hyperlipidemia, paranoid schizophrenia, atherosclerotic heart disease of native coronary arteries, gastro-esophageal reflux disease (GERD), neuromuscular dysfunction of bladder, and constipation. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 02/12/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #33 was cognitively intact. Observation on 03/24/25 at 9:12 A.M. of Resident #33's room revealed the windowsill on the bottom of her window was missing and the wind could be heard and felt…

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 of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 57 residents in the facility. The census was 57. Findings include: 1. Observation on 12/24/24 at 8:15 A.M. in House #4 revealed a refrigerator with an opened and undated carton of broccoli soup, an opened and undated carton of potato soup, and a plastic reusable bag of food without a label or date. Further observation of a second refrigerator revealed what appeared to be several paper towels lying flat underneath the bottom drawer with a pinkish/red tint to them. Interview and observation on 12/24/24 at approximately 8:20 A.M. with Certified Nurse Aide (CNA) #101 confirmed the food items were opened, unlabeled, and undated. CNA #101 further confirmed the item under the bottom drawer of the refrigerator appeared to be paper towels and were pink/red in color. 2. Observation on 12/24/24 at 8:30 A.M. in House #2 revealed a refrigerator in the kitchen area with an opened and undated container of…

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

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents except 12 (#13, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, and #68) residents residing in House #5. The facility census was 57. Findings include: 1. Observation and interview on 12/24/24 at 1:36 P.M. with Maintenance Director (MD) #301 in House #1 revealed a kitchen cabinet under the sink. Further observation revealed the floor of the cabinet was collapsed and the veneer was separated from the particle board on the floor of the cabinet. The cabinet measured approximately three feet and 10 inches wide. MD #301 confirmed the back wall of the cabinet was modified to allow for plumbing and therefore the back wall did not touch the base or side walls of the cabinet. MD #301 confirmed approximately three inches of drywall were visible between the cabinet floor and the bottom of the back wall. MD #301 confirmed a black and dark brown substance was visible on the drywall across the three feet and 10 inch width of the cabinet. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to notify the physician of changes in resident condition. This affected two (Residents #23 and' #8) of three residents reviewed for changes in condition. The facility census was 48. Findings include 1. Review of medical record revealed Resident #23 had an admission date of 01/21/22. Diagnoses included end stage renal disease, type two diabetes mellitus, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS) assessment completed 10/05/23 revealed the resident had intact cognition. Review of the care plan initiated 06/07/23 for Resident #23 revealed actual skin breakdown related to diabetes. The resident had a diabetic ulcer to the left first toe. Interventions included monitoring effectiveness of treatment and notify physician or nurse practitioner as needed if area worsens or does not respond; and monitor for infection at site as evidenced by redness, edema. Review of a nurse's note date 09/17/23 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 review of a physician wound note, review of physician orders, review of the medication administration record, staff interview, and policy review, the facility failed to ensure intravenous (IV) medications were administered per physician orders. This affected one (Resident #23) of one resident reviewed for medication administration. The facility census was 48. Findings include Review of medical record revealed Resident #23 had an admission date of 01/21/22. Diagnoses included end stage renal disease, type two diabetes mellitus, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS) assessment completed 10/05/23 revealed the resident had intact cognition. Review of a wound care note dated 09/27/23 revealed the resident had a diabetic wound to the left first toe. The physician noted the wound was exacerbated due to infection. A subsequent x-ray on 09/27/23 suggested osteomyelitis. The physician recommended an Intravenous (IV) antibiotic ancef 500 milligrams (mg) every eight hours for three days, then when the IV antibiotic was completed, start an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and policy review, the facility failed to ensure residents rinsed and swished out their mouths following the administration of an inhaled medication. This affected one resident (#13) of two residents observed for medication administration. The facility census was 55. Findings included: Review of Resident #13's medical record revealed an admission date of 08/20/22. Diagnoses included chronic respiratory failure, pulmonary fibrosis, epilepsy, and chronic obstructive pulmonary disease. Review of Resident #13's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision and set up help for eating. Review of Resident #13's current care plan revealed he had an alteration in respiratory status related to pulmonary fibrosis. Interventions were to monitor respiratory status. Review of Resident #13's physician's orders revealed an order dated 08/01/23 for Advair Diskus aerosol powder breath activated 500-50…

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 policy review, the facility failed to ensure foods were properly stored in accordance with safe food handling procedures. This had the potential to affect all 52 residents who ate meals from the facility kitchen. The facility identified one resident (#04) received no food from the kitchen. The facility census was 53. Findings include: Observation on 11/14/22 at 8:14 A.M. of the kitchen in building 5085 revealed a reach in refrigerator and freezer combination unit in the back storage area. Further observation of the refrigerator revealed an opened package of uncured salami deli meat dated 10/20/22, an opened package of hot dogs dated 10/27/22 and an opened package of sliced pepperoni dated 10/20/22. Observation of the reach in freezer in the back storage room revealed an opened, undated and unsealed package of cauliflower and an opened, undated and unsealed package of french fries. Further observation of the reach in refrigerator and freezer combination unit located in the kitchen area revealed an opened, undated and unsealed package of…

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

Based on observation and staff and resident interview, the facility failed to maintain a clean and well-maintained environment. This affected six residents (#06, #12, #20, #24, #30, and #39) and had the potential to affect all 53 residents residing in the facility. Finding include: 1. Observation of Resident #30's bedroom on 11/14/22 at 12:46 P.M. revealed a large red stain and food debris on the carpet beside Resident #30's bed underneath Resident #30's feet as he was sitting at the side of the bed. Interview on 11/14/22 at 12:48 P.M., with Resident #30 stated he was not sure what the red stain was from or how long it had been on the carpet. Observation of Resident #30's bedroom on 11/15/22 at 1:54 P.M. and on 11/16/22 at 3:12 P.M. revealed the red stain on the carpet in Resident #30's bedroom remained unchanged. A follow-up interview on 11/16/22 at 3:12 P.M., with Resident #30 stated no one had been in to clean his carpet over the last two days and stated he did not like that the stain was on the carpet where he could see it. Interview on 11/16/22 at 3:16 P.M., with State Tested…

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 the safety data sheets, and policy review, the facility failed to ensure potentially hazardous chemicals were properly stored. This had the potential to affect four residents (#01, #27, #36 and #52) out of 11 residents residing in building 5060 identified by the facility as being cognitively impaired and independently mobile. The facility census was 53. Findings include: Observation on 11/14/22 at 9:11 A.M. of the laundry room in building 5060 revealed the door was unlocked. Upon entrance to the room, an unlocked, uncovered cart containing cleaning supplies was observed. The cart was holding the following visible and accessible cleaning supplies: a half-full 32 ounce bottle of bathroom foam cleaner, a three-quarter full 24 ounce bottle of glass cleaner, a three-quarter full 24 ounce bottle of disinfectant bathroom cleaner, a half-full 24 ounce bottle of food surface sanitizer, a one-third full 24 ounce bottle of odor eliminator and a full bottle of toilet bowel cleaner. Sitting in front of the washing maching was a full one gallon…

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 policy review, the facility failed to ensure timely physician and representative notification of a significant and severe weight loss. This affected two residents (#20 and #39) out of six residents reviewed for nutrition. The facility census was 53. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 02/05/22 and a readmission date of 03/07/22. Diagnoses included multiple sclerosis (MS), neuromuscular dysfunction of bladder, major depressive disorder, polyneuropathy, contracture left ankle, contracture right ankle, contracture right knee and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was moderately cognitively impaired, required extensive assistance with eating, transfers, bed mobility, toilet use, dressing and personal hygiene. In addition, Resident #20 had significant weight loss and was not on a prescribed weight loss program. Review of a plan of…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was updated to include interventions related to fluid restrictions. This affected one resident (#50) out of six resident care plans reviewed for nutrition. The facility identified Resident #50 as the only resident with orders for a fluid restriction. The facility census was 53. Findings include: Review of Resident #50's medical record revealed an original admission date of 06/05/20 and a re-admission date of 10/16/21. Diagnoses included acute transverse myelitis in demyelinating disease of the central nervous system, diabetes mellitus type II with diabetic chronic kidney disease, end stage renal disease, paraplegia, hyperkalemia, and essential hypertension. Review of the Minimum Data Set (MDS) assessment completed 10/24/22 revealed Resident #50 was assessed with intact cognition and required supervision only with set up assistance for eating. Review of a physician order dated 04/08/22 revealed Resident #50 was ordered a no added salt, regular texture, thin…

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 resident and staff interview, the facility failed to ensure residents that required assistance with bathing were provided adequate care and services. This affected two residents (#29 and #6) out of four residents reviewed for activities of daily living. The facility identified 52 residents that required staff assistance with bathing. The census was 53. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 01/24/22. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, diabetes mellitus type II, atrial fibrillation, congestive heart failure, major depressive disorder, and difficulty walking. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was assessed with moderately impaired cognitive skills for daily decision making and required one person physical assistance with part of the bathing activity. The activities of daily living (ADLs) Care Area Assessment (CAA) as part 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, medical record review, resident and staff interview, and policy review, the facility failed to ensure wound care supplies were available to provide treatments as ordered. This affected one resident (#50) out of three residents reviewed with wounds. The facility identified six residents with non-pressure related skin wounds. Additionally, the facility failed to ensure compression stockings were applied per physician order. This affected one resident (#13) out of one resident reviewed for edema. The facility census was 53. Findings include: 1. Review of Resident #50's medical record revealed an original admission date of 06/05/20 and a re-admission date of 10/16/21. Diagnoses included acute transverse myelitis in demyelinating disease of the central nervous system, diabetes mellitus type II with diabetic chronic kidney disease, end stage renal disease, paraplegia, hyperkalemia, and essential hypertension. Review of the Minimum Data Set (MDS) assessment completed 10/24/22 revealed Resident #50…

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, staff interview, observation, and policy review, the facility failed to ensure treatments were provided as ordered to promote wound healing. This affected one resident (#12) out of three residents reviewed for pressure ulcers. The facility census was 53. Findings include: Review of Resident #12's medical record revealed an admission date of 11/06/09. Diagnoses included muscular dystrophy, torticollis, idiopathic scoliosis, protein calorie malnutrition, morbid obesity, depressive disorder, anxiety, chronic peripheral venous insufficiency, hyperlipidemia, osteoarthritis, gastroesophageal reflux, and Barrett's esophagus with dysplasia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact, required extensive assistance for bed mobility, locomotion, dressing, toilet use and personal hygiene with total dependence needed for transfers. Supervision for eating. Two-person physical assist required for bathing. Resident #12 was always incontinent…

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, staff interview, and policy review, the facility failed to provide adequate services for the respiratory care needs. This affected one resident (#11) out of two residents reviewed for respiratory care. The facility census was 53. Findings include: Review of Resident #11's medical record revealed an admission date of 07/06/22. Diagnoses included cerebral infarct, dysphagia, gastro-esophageal reflux, dementia, hemiplegia, schizophrenia, diabetes mellitus, type II, hypertension, major depressive disorder, anxiety disorder, and seizures. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired, required extensive assistance with bed mobility, dressing, eating, and personal hygiene and was totally dependent for transfers, locomotion, toilet use and bathing with one physical assist. Review of the plan of care initiated 07/11/22 revealed an alteration in oxygenation status. Interventions included head of the bed to be…

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 policy review, the facility failed to ensure medications were available from the pharmacy for administration as ordered. This affected one resident (#06) out of one resident reviewed for pharmacy services. The facility census was 53. Findings include: Review of Resident #06's medical record revealed an admission date of 02/27/17 and a readmission date of 01/21/22. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure, stage III chronic kidney disease, generalized anxiety disorder, major depressive disorder, Alzheimer's disease, osteoporosis, hypertension and COVID-19. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #06 was cognitively intact. Review of a plan of care focus area initiated 11/06/22 revealed Resident #06 was positive for COVID-19 and was on droplet and contact precautions in a private room to prevent the spread of the virus. Interventions included all medications, meals, therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, family and staff interview, and policy review, the facility failed to ensure resident meal textures were served as physician ordered. This affected one resident (#01) out of six residents reviewed for nutrition. The facility identified one resident (#01) received a physician ordered puree texture diet. The facility census was 53. Findings include: Review of Resident #01's medical record revealed an admission date of 05/08/19. Diagnoses included Alzheimer's disease, atherosclerotic heart disease, unspecified atrial fibrillation, hypertension, overactive bladder, unspecified severe protein-calorie malnutrition and stage three chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was severely cognitively impaired, required supervision for eating and had a mechanically altered diet. Review of a plan of care focus area revised 10/13/22 revealed Resident #01 was at possible risk for altered nutritional status…

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 policy review, the facility failed to ensure appropriate hand hygiene between resident contacts during medication administration. This affected four (Resident #10, #23, #33, #37) of five residents observed for medication administration. In addition, the facility failed to implement their policy for water management to reduce the risk of Legionella in the facility water. This had the ability to affect all 47 residents residing in the facility. Findings include 1. Observation of medication administration on 09/04/19 at 10:07 A.M. revealed Licensed Practical Nurse (LPN) #109 prepared and administered medications for Resident #10, returned to the medication cart, and placed the used medications supplies into the garbage receptacle on the side of the cart. LPN #109 continued to administer medications to Resident #23, #33, #37 without washing hands or using sanitizing gel between resident medication administration. Interview on 09/04/19 at 10:25 A.M., LPN #109 verified he/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, staff interview and policy review revealed the facility failed to date mark and label food stored in the freezer. This had the ability to affect 10 residents (#1, #7, #8, #9, #18, #20, #22, #24, #28 and #36) residing in House 5069. The facility census was 47. Findings include: Observation of House 5069's kitchen was completed on 09/03/19 at 10:24 A.M. with Elder Assistant (EA) #114. Inspection of the chest freezer revealed a clear, zip lock package of two chicken breasts were not labeled nor dated. In addition, a clear, zip lock package of three hamburger patties were found to not be labeled nor dated. Interview with EA #114 on 09/03/19 at 10:33 A.M. verified the facility failed to label and date the frozen food items. Review of the facility policy titled Food Storage Policy and Procedure, dated 10/01/09, revealed staff assure all food is stored, labeled and dated properly to assure stock rotation and prevent food illness. The facility identified 10 residents (#1, #7, #8, #9, #18, #20, #22, #24, #28 and #36) residing in House 5069.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, review of weekly cleaning schedules, review of resident council meeting minutes, review of work request forms, and review of facility policy, the facility failed to ensure resident rooms were clean and sanitary. Additionally the facility failed to ensure adequate room temperatures. This affected three (#16, #29, #37) of four residents reviewed for environment. The facility census 47. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 06/13/08. Diagnoses included quadriplegia, neuromuscular dysfunction of bladder, anxiety disorder, major depressive disorder, primary osteoarthritis, pneumonia, and muscle weakness. Review of the last Minimum Data Set (MDS) assessment, dated 07/17/19, revealed the resident had intact cognition. Observation on 09/03/19 at 9:45 A.M. revealed a shelving unit estimated ten feet long and six feet high cluttered with electronics, books, picture frames, and other miscellaneous items.…

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, staff interview, and facility policy review, the facility failed to notify the physician of a new pressure ulcer, failed to perform treatments only upon order of physician, failed to update the care plan and interventions when a pressure ulcer was present, and failed to provide weekly monitoring and assessment of the pressure ulcer which included assessment of wound bed, staging of the area, and documentation of any drainage. This affected one (#29) of one resident reviewed for pressure ulcers. The facility identified one resident with pressure ulcers. The facility census was 47. Findings include: Review of the medical record for Resident #29 revealed an admission date of 06/13/08. Diagnoses included quadriplegia, neuromuscular dysfunction of bladder, anxiety disorder, major depressive disorder, primary osteoarthritis, pneumonia, and muscle weakness. The resident readmitted to the facility on [DATE] following a hospitalization for pneumonia. Review of Resident #29's quarterly Minimum Data…

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

Based on medical record review, observation, staff interviews and review of facility policy, the facility failed to implement a verbal physician order to schedule a resident's gastrostomy tube replacement after the feeding tube dislodged. This affected one (#41) of one resident reviewed for tube feedings. The facility had two residents with tube feedings. The facility census was 47. Findings include Medical record review revealed Resident #41 had an admission date of 04/27/09. Diagnoses included hemiplegia of the right dominant side, aphasia following cerebral infarction, and dysphagia. Review of a nurse's note dated 08/26/19 at 11:52 P.M. revealed Resident #41's feeding tube was lying on the bed. The nurse used a 16 French Foley catheter to replace the feeding tube. The nurse notified the Director of Nursing (DON). The nurse documented the nurse practitioner would be at the facility in the morning and updated on the situation. Further review of the nurses' notes from 08/26/19 through 09/03/19 revealed no documentation the physician or nurse practitioner was notified regarding 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, staff interview, and review of the dialysis center transfer agreement, the facility failed to document ongoing communication with the dialysis center. This affected one (Resident #40) of one dialysis residents in the facility. The census was 47. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/08/19. Diagnoses included vascular dementia without behavioral disturbance, hypertension, hyperlipidemia, chronic kidney disease, dependence on renal dialysis, type 2 diabetes, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 08/08/19, revealed the resident had intact cognition. Review of Resident #40's physician orders revealed Resident #40 received dialysis Monday, Wednesday, and Friday outside the facility. Review of Resident #40's medical record revealed there was no evidence of communication with the dialysis center. Interview on 09/05/19 at 9:13 A.M. with the Director of Nursing (DON) #102 verified the facility did not have communication with the dialysis center. 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 observations, resident interviews, staff interviews, review of work request forms, and review of facility policy, the facility failed to take steps to eradicate ants from the room of one (#29) of one residents reviewed for pest control. The facility census was 47. Findings include: Review of the medical record for Resident #29 revealed an admission date of 06/13/08. Diagnoses included quadriplegia, neuromuscular dysfunction of bladder, anxiety disorder, major depressive disorder, primary osteoarthritis, pneumonia, and muscle weakness. Review of the most current Minimum Data Set (MDS) assessment, dated 07/17/19, revealed the resident had intact cognition. Interview on 09/03/19 at 9:38 A.M. with Resident #29 revealed a can of soda had spilled five to six days ago in his/her room. Resident #29 stated his/her visitor and a facility staff member helped clean up the soda but ants appeared a couple of days ago. Resident #29 reported a loaf of bread needed to be thrown away because of ants. Resident #29 stated facility staff were aware and an ant was found in her bed. Observation…

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.