Majestic Care Of New Lexington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident receiving an anti-hypertensive medication had his blood pressure obtained and recorded at the time of the anti-hypertensive medications administration, when the physician's orders included parameters to notify the physician if the resident's systolic blood pressure (SBP) was greater than 100 millimeters of mercury (mmHg). This affected one (Resident #5) of five residents reviewed for unnecessary medications.Findings include: Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included the diagnosis of hypertension (high blood pressure). Review of Resident #5's physician's orders revealed the resident had an order in place to receive Metoprolol Succinate (a beta blocker used in the treatment of hypertension) Extended Release (ER) 25 milligrams (mg) by mouth every night at bedtime for hypertension. The order included a parameter to call the physician, if the resident's SBP (top…

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 complete lab work as physician ordered. This affected one (#68) of five residents reviewed for unnecessary medications. The facility census was 70.Findings include:Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including Parkinson's disease and edema.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68's cognition was intact.Review of the physician orders revealed on 07/30/24, Resident #68 would have the following laboratory (lab) blood draws every three months (August, November, February, and May): complete blood count (CBC), basic metabolic panel, vitamin D, B12, lipid panel, liver panel, and prealbumin.The care plan dated 03/28/25 revealed Resident #68 was at risk for fluid imbalance due to diuretic use related to edema. Interventions included lab work as ordered. Review of the laboratory results revealed Resident #68 last had lab work completed on 08/28/25. There were no lab…

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 policy review, the facility failed to ensure a resident received timely dental services. This affected one (#25) of one resident reviewed for dental care. The facility census was 70.Findings include:Review of the medical record for Resident #25 revealed an admission date of 11/30/23 with diagnoses including dementia with behavioral disturbance, depression, dysphagia, and anxiety disorder.Review of the dental consult dated 09/11/25 revealed Resident #25 had a referral to an oral surgeon to extract of all symptomatic teeth.The progress note dated 09/16/25 authored by Transportation Aide (TA) #176 revealed they a faxed referral to Dental Clinic #1. On 10/15/25 a progress note authored by TA #176 indicating a referral was faxed to referral to Oral Surgery and Dental Implants #2. On 10/22/25, a telephone call placed to Oral Surgery and Dental Implants #2 asking if they take Medicaid. On 11/07/25, an email was sent to Family Dental #3 by TA #176. The dental consult 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 record review and staff interview, the facility failed to ensure the resident's medical record had accurate documentation for care related to a resident's Jackson Pratt (JP) drain. This affected one (Resident #60) of 23 residents reviewed for medical record accuracy.Findings include:Review of Resident #60's closed medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of her rectum and status post colostomy placement. She remained in the facility until 03/04/26, when she was discharged home. Review of Resident #60's initial skin evaluation completed on 01/28/26 revealed one JP drain (a closed-suction medical device used after surgery to remove excess fluid from the body, preventing infection and promoting healing; it consisted of a silicone tube connected to a bulb that, when squeezed, created a gentle vacuum to pull fluid into a collection chamber) was present to her lower abdominal area. The other two JP drains were indicated to be 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 and staff interview, the facility failed to provide ordered treatment of a thoracic abscess, daily weights and monitoring intake and outputs for a resident on fluid restrictions. This affected two residents (#39, #66) of eight resident records reviewed. The census was 63. Findings include:1. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including methicillin susceptible staphylococcus aureus (MSSA) infection, endocarditis, and altered mental status. Resident #66 discharged from the facility on 12/26/25. Review of an email sent to the facility on [DATE] revealed Resident #66 would need a wound vac and orders were attached. Review of an order dated 12/04/25 revealed Resident #66's wound needed a wound vac for a wound to left chest at pressure setting 125 (standard) with no wound vac cover, the wound vac dressing would need changed three times a week and as needed, cover with white foam and wound cleanser would be normal saline. The suction…

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 obtain laboratory services as ordered. This affected one resident (#39) of eight resident records reviewed. The census was 63. Findings included:Review of Resident #39's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, pressure ulcer unstageable and diabetes.Review of the admission minimum data set (MDS) dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating, oral hygiene, dependent for toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident #39 had an indwelling catheter and was frequently incontinent of bowel. Further review revealed a physician's order on 12/04/25 for a complete blood count (CBC), e-diff (electronic differential), platelets, basic metabolic profile (BMP) without glucose, hepatic function panel weekly…

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 interviews, observations and facility policy, the facility failed to maintain a safe and homelike environment for four residents ( #11, #20, #30, and #40) of four residents reviewed. The facility census was 56. Findings include: Observation on 03/31/25 at 12:35 P.M. of private room [ROOM NUMBER] revealed in the bathroom, a small quarter size rusted hole through the sink. Interview on 03/31/25 at 12:59 P.M. with the Director of Nursing revealed the facility did an audit for the entire facility on resident's bathroom conditions on 03/06/25 and found two sinks that had rusted holes found in room [ROOM NUMBER] as well as the shared bathroom for rooms #106 and #108. Verified room [ROOM NUMBER] is now unoccupied, but did have Resident #11 when she was at the facility. room [ROOM NUMBER] has Resident #30 and #40 currently and room [ROOM NUMBER] has Resident #20 currently. Observed on 03/31/25 at 1:21 P.M. of the shared bathroom for rooms #106 and #108 revealed a baseball sized hole that was rusted through 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 interviews, record reviews, and facility validation accessing implanted vascular access port guidelines the facility failed to ensure an antibiotic was ordered correctly and an implanted vascular access port (port a cath) was accessed with a physician's order. This affected one resident (#11) of two residents reviewed for indwelling devices and antibiotics. The facility census was 56. Findings include: Review of the medical record for Resident #11, revealed an admission date of 02/12/25 and a was sent to the hospital when at Fairfield Healthcare Professional Hematology and Oncology infusion appointment on 03/07/25. Diagnoses included but were not limited to partial intestinal obstruction, malignant neoplasm of colon, moderate protein-calorie malnutrition, osteoarthritis, iron deficient anemia, essential hypertension and personal history of venous thrombosis and embolism. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident, who was dependent on staff for personal care, received the assistance needed with routine incontinence care and repositioning as needed when up in her wheelchair. This affected one (Resident #39) of three residents reviewed. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (MS), cognitive communication deficit, abnormal posture, scoliosis, morbid obesity, mild cognitive impairment of uncertain or unknown etiology, and chronic pain syndrome. Review of Resident #39's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired, she was not known to display any behaviors nor was she known to reject care. She had a functional limitation in range…

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 begin the discharge planning process upon admission. This affected one (Resident #39) of one residents reviewed for choices. The facility census was 62. Findings included: Record review revealed Resident #39 admitted to the facility on [DATE] with diagnoses including chronic and acute respiratory failure, muscle weakness, and difficulty in walking. Review of an assessment titled Interdisciplinary Care Conference Summary dated 10/04/24 revealed Resident #39 would receive long term care and would apply for Medicaid. Review of the sign in sheet for the care conference revealed only the social worker and nursing staff signed in. The resident and family did not sign in. Review of an admission minimum data set (MDS) completed on 10/08/24 revealed Resident #39 remained cognitively intact, had no behaviors, and had a discharge goal to remain in the facility. Review of a care plan dated 10/22/24 revealed Resident #39 would remain in the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to maintain a comprehensive plan of care and properly implement pressure relieving interventions. This affected one resident (#165) of two residents reviewed for pressure ulcers. The facility census was 62. Findings include: Review of the medical record for Resident #165 revealed an admission date of 10/19/24. Diagnoses included but were not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of right and left leg above the knees, type 2 diabetes, depression and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The resident was assessed to require partial/moderate assistance with bed mobility, dependence with toilet hygiene and transfers. No wound assessment was completed due to assessment still in progress from being a new…

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 set parameters for as needed diuretic medication based on weight gain. This affected one of six residents (Resident#50) sampled for unnecessary medications. The facility census was 62. Findings include: Review of Resident #50's medical record revealed an admission date of 01/05/23 with diagnoses including acute systolic congestive heart failure, myocardial infarction, nonrheumatic aortic (valve) stenosis, and anxiety. Review of the quarterly Minimum Data Set(MDS) dated [DATE] revealed the resident had severe cognitive impairment. Further review of the MDS revealed an active diagnosis for heart failure. Review of Resident #50's physician's orders revealed an order for furosemide oral tablet (a diuretic medication), give 20 milligrams (mg) by mouth every 24 hours as needed for weight gain and an order to weigh the resident daily. Review of Resident #50's care plan revealed no care plans were present for the use of diuretic medication, daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review, the facility failed to maintain infection control procedures during a dressing change. This affected one (Resident #18) of two residents reviewed for pressure ulcers. The census was 62. Findings include: Review of Resident #18's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, paraplegia, peripheral vascular disease (PVD) and anxiety. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact (BIMS of 15). Functional limitations in range of motion to the lower extremities (Impairment on both sides), and used a wheelchair for mobility. The resident had an indwelling suprapubic (a tube that drains urine through a small incision in the abdomen) urinary catheter and was always incontinent of bowel. Review of the physicians orders revealed an order to cleanse the coccyx area with wound cleanser, pat dry, apply medihoney (a medical grade honey…

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, interviews, and review of the AccuWeather forecast the facility failed to ensure Resident #29's window was shut during cold weather. This affected one resident (#29) of three sampled residents reviewed. The facility census was 60. Findings Include: Review of the medical record for Resident #29 revealed an initial admission date of 06/08/19 with the latest readmission of 02/12/24 with diagnoses including fracture of lower end of right ulna, pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, metabolic encephalopathy, multiple sclerosis (MS), dysphagia, osteoarthritis, dry eye syndrome, hyperlipidemia, chronic pain syndrome, scoliosis, insomnia, hypothyroidism, major depressive disorder, repeated falls, anxiety disorder and constipation. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had unclear speech, usually made herself understood, usually understood others, and had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide showers as scheduled and per resident preference. This affected two residents (#13, #22) of five residents reviewed for quality of care. The facility census was 59. Findings included: 1. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, paraplegia, and chronic fatigue. Review of a minimum data set (MDS) completed on 10/20/23 revealed Resident #13 maintains capacity, it is very important to him to choose between a tub bath, shower, sponge bath or bed bath, and is dependent on staff for bathing. Review of a care plan completed on 11/10/23 revealed Resident #13 prefers to have showers in the afternoon. Review of a shower schedule revealed Resident #13 was scheduled to receive showers on Mondays, Wednesdays, and Fridays. Review of shower documentation revealed Resident #13 received a bed bath on 01/17/24, a bed bath on 01/19/24, was not applicable on 01/22/24, a bed bath 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 and interview, the facility failed to provide access to medical records. This affected one resident (#82) of one residents reviewed for medical records. The facility census was 59. Findings included: Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, orthostatic hypotension, non-st elevation myocardial infarction, bipolar disorder, congestive heart failure, major depression, anemia, hypertension, and cardiomegaly. Review of a minimum data set completed on 11/17/23 revealed Resident #82's cognition did not remain intact, did not have behaviors, she used a walker and a wheelchair, required maximum assistance for toileting hygiene, maximum assistance for toilet transfers, moderate assistance to walk 10 feet, was dependent for wheelchair use, and was occasionally incontinent. Resident #82 had a durable power of attorney (DPOA). Review of the medical record did not contain any evidence the facility processed a request…

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 maintain accurate care plans to reflect current mobility status. This affected one resident (#82) of four residents reviewed for falls. The facility census was 59. Findings included: Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, orthostatic hypotension, non-st elevation myocardial infarction, bipolar disorder, congestive heart failure, major depression, anemia, hypertension, and cardiomegaly. Review of a minimum data set completed on 11/17/23 revealed Resident #82's cognition did not remain intact, did not have behaviors, she used a walker and a wheelchair, required maximum assistance for toileting hygiene, maximum assistance for toilet transfers, moderate assistance to walk 10 feet, was dependent for wheelchair use, and was occasionally incontinent. Review of a hospice note dated 01/29/24 revealed Resident #82 was no longer able to walk, unable to stand and pivot…

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 communicate a speech therapy recommendation to the physician thereby delaying a diagnostic test. This affected one resident (#34) of five residents reviewed for quality of care. The facility census was 59. Findings included: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including pulmonary embolism, altered mental status, unspecified dementia, and hypertension. Review of a minimum data set (MDS) completed on 12/07/23 revealed Resident #34 had no signs of a swallowing disorder, had a five percent or greater weight loss in one month or ten percent or greater weight loss in the last six months without being on a prescribed weight-loss regimen, and was receiving a mechanically altered diet. Review of a care plan updated on 02/02/24 revealed Resident #34 had a potential from nutritional problem related to advanced age, dementia, morbid obesity, mechanically altered diet, moisture associated skin damage, varied…

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 interviews, the facility failed to replace Resident #62's broken glasses. This affected one resident (#62) of four residents reviewed for accidents. The facility census was 59. Findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, osteoarthritis, dry eye syndrome of unspecified lacrimal gland, hyperlipidemia, chronic pain syndrome, scoliosis, repeated falls, mild cognitive impairment, anxiety, and major depression. Care plan review revealed Resident #34 was at risk for falls related to multiple sclerosis, chronic pain, psychiatric medication use, pain medication use, and incontinence of bladder. Interventions included placing glasses within reach and encourage use. Review of a preliminary list for a vision clinic for 03/19/24 revealed Resident #62 was not on the list for the upcoming eye doctor appointment. Observation on 02/13/24 at 1:57 P.M. of Resident #62 revealed the 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 interview, record review and Ohio Revised Code review, the facility failed to ensure a resident was permitted to choose his Power of Attorney (POA) and failed to ensure POA paperwork was legal. This affected one resident (#63) of three residents reviewed for POA concerns. The facility census was 60. Findings included: Review of Resident #63's closed medical record revealed an admission date of [DATE] with diagnoses including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology, urine retention, and essential hypertension. He expired in the facility on [DATE]. Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he was cognitively impaired. Review of Resident #63's Clinical Resident Profile revealed Licensed Practical Nurse (LPN) #2 was his POA. Review of Resident #63's State of Ohio Health Care Power of Attorney, dated [DATE], revealed it was signed by the Principal (Resident #63) and witnessed by LPN #1 providing LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and facility policy review, the facility failed to ensure vascular wounds were properly assessed, treatments were completed as ordered by the physician, and a care plan was developed for his vascular wounds to meet the resident needs. This affected one resident (#63) of three residents reviewed for wounds. The facility census was 60. Findings included: Review of Resident #63's medical record revealed an admission date of [DATE] with diagnoses including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology, urine retention, and essential hypertension. He expired in the facility on [DATE]. Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he was cognitively impaired. Further review also revealed he did not have any venous or arterial ulcers and no other skin issues.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and facility policy review, the facility failed to ensure pressure ulcer treatments were completed as ordered by the physician and a care plan was developed to meet the resident needs. This affected one resident (#63) of three residents reviewed for wounds. The facility census was 60. Findings included: Review of Resident #63's closed medical record revealed an admission date of [DATE] with diagnoses including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology, urine retention, and essential hypertension. He expired in the facility on [DATE]. Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he was cognitively impaired. Further review also revealed he did not have any pressure ulcers and no other skin issues. Review of Resident #63's Skin Grid Pressure, dated [DATE],…

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 weights were obtained for a new admission to the facility and failed to ensure weights were completed per physician order. This affected one resident (#63) of three residents reviewed for weight loss. The facility census was 60. Findings included: Review of Resident #63's closed medical record revealed an admission date of [DATE] with diagnoses including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology, urine retention, and essential hypertension. He expired in the facility on [DATE]. Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he was cognitively impaired. He had no or unknown weight loss or gain and was on a therapeutic diet. Review of Resident #63's weights revealed his first weight was completed on [DATE] and he weighed 174.2 pounds; his second weight was on [DATE] and he weighed 177.0 pounds, and his next weight was 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 review of resident fund accounts and staff interview, the facility failed to notify each resident that received Medicaid benefits when the amount in the account reached $200 less that the resource limit for one person. This affected three of five residents whose fund accounts were reviewed (Residents #8, #42, and #43). Findings include: 1. Review of the resident fund account for Resident #8 revealed a balance on 06/03/22 of $3623.23. The balance remained above $1800.00 until 07/29/22 when it was $1779.72. On 08/03/22 the balance went to $3641.75. As of 09/01/22, the balance remained above $1800.00 and was $1830.75. There was no evidence the resident/responsible party was notified that the balance had reached $200 less than the resource limit. This was confirmed by the Business Office Manager on 09/01/22 at 2:40 P.M. 2. Review of the resident fund account for Resident #42 revealed a balance on 08/03/22 of $3171.17. The balance remained above $1800.00 as of 09/01/22, with a balance of $1800.67. There was no evidence the resident/responsible party was notified that the balance…

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 staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed to trim and clean her fingernails. This affected one (Resident #23) of two residents reviewed for activities of daily living (ADL's). Findings include: A review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, type II (adult onset) diabetes mellitus, dementia without behavioral disturbances, major depressive disorder osteoarthritis, chronic pain, and vision problems. A review of Resident #23's active physician's orders revealed she had been admitted under the care and services of hospice. The diagnosis for admission to hospice was Parkinson's disease. A review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had clear speech. She was sometimes able to make herself understood and was sometimes able to understand others.…

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, and interview, the facility failed to identify and monitor bruising for a resident receiving oral anticoagulants, who was noted with a bruise to the upper right arm. This affected one (Resident #29) of the five residents reviewed for medication review. Findings include: Review of the medical record for Resident #29 revealed an admission date of 06/04/22. Diagnoses included aftercare following surgical amputation, atherosclerosis of native arteries of the bilateral lower extremities, and peripheral vascular disease. Review of Resident #29's comprehension Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had an intact cognition for daily decision making abilities. Resident #29 required limited assistance from two staff members for bed mobility, and extensive assistance from two staff members for transfers, dressing, toilet use, and personal hygiene. Resident #29 was noted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's contingency drug supply, review of pharmacy receipts, policy review and staff interview, the facility failed to ensure a resident received an antibiotic as ordered by the physician for the treatment of a urinary tract infection (UTI). This affected one (Resident #9) of one resident reviewed for UTI's. Findings include: A review of Resident #9's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, schizophrenia, schizo-affective disorder, and mild intellectual disability. She did not have recurrent UTI's or other urinary related diagnoses noted on her diagnoses list. A review of Resident #9's nurses' progress notes revealed she had a nurse's note dated 07/03/22 that revealed the resident had complaints of burning with urination. The physician was notified and a new order was received to obtain a urinalysis and culture and sensitivity (U/A C&S) in indicated to be obtained on 07/06/22. The obtaining 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, review of the facility's contingency drug supply, review of pharmacy receipts, policy review and staff interview, the facility failed to ensure antibiotics ordered for the treatment of urinary tract infections (UTI's) were readily made available by their contracted pharmacy for timely administration and to ensure antibiotic therapy could be completed as ordered by the physician. This affected one (Resident #9) of one residents reviewed for UTI's. Findings include: A review of Resident #9's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, schizophrenia, schizo-affective disorder, and mild intellectual disability. She did not have recurrent UTI's or other urinary related diagnoses noted on her diagnoses list. A review of Resident #9's nurses' progress notes revealed she had a nurse's note dated 07/03/22 that revealed the resident had complaints of burning with urination. The physician was notified and a new order was received to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, the facility failed to ensure antipsychotic medications were not used without an adequate indication for use. This affected two (Resident #10 and #48) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease and dementia without behavioral disturbances. A review of Resident #10's active physician's orders revealed the resident was receiving Seroquel 25 milligrams (mg) by mouth (po) every night at bedtime for mood swings and agitation. The order originated on 05/10/22 but was most recently re-ordered on 05/27/22. A review of Resident #10's psychiatry notes revealed she was first seen by a psychiatrist at the facility on 04/18/22 for an initial visit. The reason for the visit was indicated to be for medication management for mood instability and lability and wandering. The history 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.