Gardens Of North Olmsted

Based on record review, interview, and facility policy review, the facility failed to ensure pain medications were available for administration. This affected one resident (#58) of three residents reviewed for medications. The facility census was 91. Findings include: Review of the medical record for Resident #58 revealed an admission date of 09/01/24 with diagnosis of rheumatoid arthritis, failure to thrive, depression, post cholecystectomy syndrome.Review of the quarterly Minimum Data Set 3.0 dated 01/07/26 revealed the resident had intact cognition and was dependent on staff for toileting and transfers. The assessment indicated the resident had pain and received scheduled and as-needed pain medications.Review of the physicians ordered for January 2026 revealed two order for pain medication. Oxycodone (a opioid analgesic) 15 milligrams (mg) to be administered every four hours and Acetaminophen (an over-the-counter mild pain reliever) 500 mg, a pain reliever, to be administered every six hours as needed. Review of the Medication Administration Record (MAR) for January 2026 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 record review, interview, and facility policy review, the facility failed to ensure medical records were accurate and complete. This affected two Residents (#3 and #58) of three residents reviewed for documentation. The facility census was 91. Findings include: 1.Record review for Resident #58 revealed an admission date of 09/01/24. Diagnosis included rheumatoid arthritis, failure to thrive, depression, anxiety, and post-traumatic stress disorder.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively intact and had moderate depression. Resident #58 had impairment on both sides of the upper and lower extremities and was dependent on staff for toileting hygiene, showers, and transfers.Review of the progress note dated 01/04/26 at 12:17 P.M. resident was exhibiting hallucinations and making accusations against staff, stating that staff is stealing her belongings, drugging her, and transferring her to another room against her will. The Resident also stated 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, record review and interview, the facility failed to ensure food portions were appropriate and food served was palatable. This affected all residents with the exception of Resident #50, who did not consume meals from the kitchen. The facility census was 75.Findings include: Observation on 12/10/25 of lunch tray line revealed a meal of spaghetti with meat sauce, garlic bread and salad being served.Review of the food temperature log revealed the log was last updated 12/04/25 for breakfast. [NAME] #218 revealed he wrote the temperatures for the day's lunch on the wrong sheet, he revealed he wrote the temperatures on 12/03/25 at dinner. He revealed the meat sauce was 180 degrees Fahrenheit (F), the noodles were 179 degrees F, the mashed potatoes were 183 degrees F, and there was no temperature obtained for the garlic bread, fruit or salad. There were also no temperatures for the pureed meat sauce or garlic bread. [NAME] #218 confirmed not all food temperatures were obtained prior to the start of the meal being served.Continued observation of tray line on 12/10/25…

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 facility policy review, the facility failed to ensure the building was in good repair and free of trash buildup. This had the potential to affect all 75 residents in the facility.Findings include: Observation on 12/09/25 at 10:42 A.M. of the basement revealed a room with two large bins of trash piled over the top as well as five to six large bags of trash on the ground. A room labeled housekeeping revealed a strong odor of mold, multiple flying insects and approximately ten clear bags filled with trash piled on top of one another, lining the left wall. Against the right wall were two large trash can sized tubs underneath a pipe running from the front of the wall toward the back of the wall which was leaking water into the tubs.Observation and interview with Laundry Aide #217 on 12/09/25 at 10:47 A.M. of the laundry area revealed water running down the brick wall next to the dryer with a black mold-like substance approximately two inches tall by 10 inches long toward the bottom of the wall. Interview at the time of the observation with Laundry Aide…

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 reviews, observations, interviews and facility policy review, the facility failed to ensure fall assessments were completed, falls were documented in the medical record, fall prevention interventions were in place, and fall investigations were thorough. This affected four (Residents #18, #22, #52 and #76) of five residents reviewed for falls. The facility census was 75. Findings include: 1. Review of Resident #52's medical record revealed an admission date of 02/13/25 with diagnoses including syncope and collapse, history of falling, anxiety disorder and type two diabetes mellitus with diabetic neuropathy. Review of Resident #52's Morse Fall Scale dated 07/30/25 revealed Resident #52 was at high risk for falling. Review of Resident #52's progress notes dated 07/31/25 through 08/04/25 did not reveal evidence Resident #52 experienced a fall on 08/01/25. Review of Resident #52's Falls Best Practice investigation dated 08/01/25 at 8:30 P.M. revealed the investigation was not found in Resident #52's…

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 reviews, observations, interviews and review of manufacturer instructions, the failed to ensure Resident #22's stoma supplies were available timely and failed to ensure Resident #75 had a working television. This affected two (Residents #65 and #75) of four residents reviewed accommodation of needs. The facility census was 75. Findings include: 1. Review of Resident #22's medical record revealed an admission date of 01/08/25 and diagnoses included vascular dementia, atherosclerotic heart disease and secondary malignant neoplasm of unspecified urinary organs. Review of Resident #22's care plan revised on 10/22/25 included Resident #22 had a urostomy related to neoplasm of the urinary organs. Resident #22 had frequent fixations on the urostomy bag by touching it, opening it, and trying to empty it and had urinary leakage on his clothing and bedding. Staff would re-direct as needed. Resident #22 would show no signs and symptoms of urinary infection through the review date. Interventions included…

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 missing items log, observation, interviews and facility policy review, the facility failed to report and allegation of misappropriation for Resident #22 to the State agency. This affected one (Resident #22) of three residents reviewed for misappropriation. The facility census was 75. Findings include:Review of the medical record for Resident #22 revealed an admission date of 01/08/25. Diagnoses included heart disease, dementia, anxiety and depression.Review of the progress note dated 06/29/25 at 1:09 P.M. revealed Resident #22's daughter reported the resident's phone had been stolen a few weeks prior and she had not yet heard from management regarding the matter. She also reported an abdominal binder missing from the resident's room. Resident #22's daughter purchased another iPhone for the resident which was to be placed in the medication cart for the resident to use when he wished.Review of the social services note dated 6/30/25 at 12:31 P.M. revealed Resident #22's…

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 missing items log, observation, interviews and facility policy review, the facility failed to thoroughly investigate missing items for Resident #22. This affected one Resident #22) of three residents reviewed for misappropriation. The facility census was 75.Findings include:Review of the medical record for Resident #22 revealed an admission date of 01/08/25. Diagnoses included heart disease, dementia, anxiety and depression.Review of the progress note dated 06/29/25 at 1:09 P.M. revealed Resident #22's daughter reported the resident's phone had been stolen a few weeks prior and she had not yet heard from management regarding the matter. She also reported an abdominal binder missing from the resident's room. Resident #22's daughter purchased another iPhone for the resident which was to be placed in the medication cart for the resident to use when he wished.Review of the social services note dated 6/30/25 at 12:31 P.M. revealed Resident #22's daughter stated her nephew told…

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, interview and review of the facility policy, the facility failed to ensure Resident #33's care conference was scheduled during the required timeframe. This affected one (Resident #33) of three residents reviewed for care conferences and had the potential to affect 10 additional residents (Resident's #6, #11, #14, #16, #23, #30, #33, #41, #45, #58, #75) identified by the facility as needing to have a care plan scheduled. The facility census was 75.Findings include:Review of Resident #33's medical record revealed an admission date of 07/09/20 with diagnoses including type two diabetes mellitus, multiple sclerosis, and neuromuscular dysfunction of the bladder. Review of Resident #33's care plan revised 06/26/25 included Resident #33's discharge plan related to long term care. Resident #33's care needs would continue to be met per plan of care daily. Interventions included providing care according to care plans to enhance optimum well-being; reassessing care needs to monitor…

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, interview and review of the facility policy, the facility failed to ensure Resident's #41, #58 and #73 were provided with appropriate care and services. This affected three residents (Resident's #41, #58 and #73) out of four residents reviewed for activities of daily living (ADL) care for dependent residents. The facility census was 75.Findings include:1. Review of the medical record for Resident #58 revealed an admission date of 07/25/23. Diagnoses included respiratory failure, diabetes, stroke affecting the left, non-dominant side, depression, heart failure, reduced mobility and chronic pain.Review of the quarterly Minimum Data Set (MDS) assessment data 09/29/25 revealed Resident #58 was moderately cognitively impaired. She required setup help for eating and was dependent on staff for oral care, toileting, showering, dressing and personal hygiene.Review of the care plan dated 09/29/25 revealed Resident #58 had an activities of daily living (ADL) self-care performance…

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 hospice records, interview and facility policy review, the facility failed to ensure changes in conditions were properly addressed for Residents #76 and #77. This affected two (Residents #76 and #77) of three residents reviewed for change in condition. The facility census was 75.Findings include:1. Review of the medical record for Resident #76 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included bipolar disorder, morbid obesity, stroke affecting the right dominant side, communication deficit, traumatic brain injury, depression and impulse disorder.Review of the quarterly Minimum Data Set (MDS) assessment date at [DATE] revealed Resident #76 was moderately cognitively impaired. She required setup help for eating and oral care, supervision for dressing, toileting and hygiene and partial assistance for showering.Review of the physicians' orders for [DATE] revealed Resident #76 had a full code status (medical instruction for full resuscitation…

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 timely identify and treat urinary tract infections for Resident's #22 and #33. This affected two residents (#22 and #33) out of three residents reviewed for urinary tract infections. The facility census was 75.Findings include:Review of Resident #22's medical record revealed an admission date of 01/08/25 and diagnoses included vascular dementia, atherosclerotic heart disease and secondary malignant neoplasm of unspecified urinary organs.Review of Resident #22's progress notes dated 10/27/25 at 2:46 A.M. revealed a urine specimen for urinalysis and culture and sensitivity was obtained and placed in the refrigerator on the first-floor nursing unit.Review of Resident #22's progress notes dated 10/28/25 at 9:00 A.M. revealed Resident #22 was not eating or drinking and was agitated and yelling. Resident #22's vital signs were checked, and a full assessment was completed. Nurse Practitioner (NP) #228 was notified and an order was given to send…

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 review of the facility policy, the facility failed to transport Resident #63 to dialysis appointments as ordered. This affected one resident (#63) out of one resident reviewed for dialysis. The facility census was 75.Findings include:Review of Resident #63's medical record revealed an admission date of 11/07/25 and diagnoses included end stage renal disease, type two diabetes without complications, and vascular dementia.Review of Resident #63's Treatment Administration Record (TAR) dated 11/10/25 through 12/14/25 revealed to monitor the right chest port (for dialysis use only) for signs and symptoms of infection (redness, drainage, foul odor, swelling, inflammation) every shift. It was checked off as completed each shift.Review of Resident #63's physician orders dated 11/11/25 revealed dialysis every Tuesday, Thursday and Saturday. Pick-up time was 9:45 A.M. and drop off was at 2:30 P.M.Review of Resident #63's care plan dated 11/10/25 and revised 12/08/25 revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #22 was provided appropriate dental services. This affected one (Resident #22) of three residents reviewed for dental services. The facility census was 75.Findings include:Review of the medical record for Resident #22 revealed an admission date of 01/08/25. Diagnoses included heart disease, dementia, anxiety and depression.Review of the dental provider notes dated 07/09/25 revealed Resident #22 was seen for upper and lower dental impressions.Review of the care plan dated 09/09/25 revealed Resident #22 had oral and dental health problems and upper and lower dentures. Interventions included coordinating arrangements for dental care, following diet orders, and documenting any signs or symptoms of oral or dental problems need attention. His dentures were identified as missing on 03/07/25.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was severely cognitively impaired. He required set up help 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 record review, staff interview, and policy review, the facility failed to ensure a resident elopement was reported to the State Agency as required. This affected one resident (Resident #129) of three residents reviewed for elopement. The facility census was 76.Findings include: Review of the medical record for Resident #129 revealed an admission date of 05/13/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, alcohol dependence with alcohol induced persisting dementia, alcohol dependence with alcohol induced psychotic disorder with hallucinations, moderate dementia with psychotic disturbance and age-related bilateral cataracts. Review of Resident #129's care plan last reviewed on 08/21/25 indicated Resident #129 was at risk for elopement due to being disoriented to place, have impaired safety awareness and dementia with wandering behaviors. Interventions listed were to distract resident from wandering and intervene as appropriate. Offer various activities throughout…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff and resident interviews, review of the in-progress facility investigation, review of a local police report, review of local weather reports, and facility policy review, the facility failed to prevent an elopement for one resident (Resident #129) of three residents reviewed for elopement. The facility census was 76. Findings include: Review of the medical record for Resident #129 revealed an admission date of 05/13/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, alcohol dependence with alcohol induced persisting dementia, alcohol dependence with alcohol induced psychotic disorder with hallucinations, moderate dementia with psychotic disturbance and age-related bilateral cataracts. Review of Resident #129's care plan last reviewed on 08/21/25 indicated Resident #129 was at risk for elopement due to being disoriented to place, have impaired safety awareness and dementia with wandering behaviors. Interventions listed were to distract…

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, interviews, and policy review, the facility failed to ensure complete medical records were maintained for one resident (Resident #129) of three records reviewed for accurate and complete medical records. The facility census was 76. Findings include:Review of the medical record for Resident #129 revealed an admission date of 05/13/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, alcohol dependence with alcohol induced persisting dementia, alcohol dependence with alcohol induced psychotic disorder with hallucinations, moderate dementia with psychotic disturbance and age-related bilateral cataracts. Review of Resident #129's care plan last reviewed on 08/21/25 indicated Resident #129 was at risk for elopement due to being disoriented to place, have impaired safety awareness and dementia with wandering behaviors. Interventions listed were to distract resident from wandering and intervene as appropriate. Offer various activities throughout the day 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 interviews, record review and observations the facility failed to ensure the courtyard was maintained in a clean and safe manner. This had the potential to affect all 72 residents in the facility. Findings Include: Interview on 06/10/25 at 8:27 A.M. with Resident #36 revealed she has been outside one time since she admitted to the facility. Interview on 06/10/25 at 8:59 A.M. with Certified Nursing Assistant (CNA) #300 revealed residents are sometimes taken outside to the courtyard. Interview on 06/11/25 at 1:33 P.M. with CNA #301 revealed they do take residents outside when it is nice outside and that she took some of the residents outside the weekend before. Interview on 06/11/12 at 1:47 P.M. with Resident #68 revealed has not seen anyone go to the courtyard and she goes outside with smokers to socialize and go outside, even though she does not smoke. Interview on 06/11/25 at 2:47 P.M. with Activities Director #305 revealed she has been asking since summer of 2024 for new outdoor patio furniture and a power washer to clean current furniture that is not broken but dirty.…

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 Resident #35, Resident #36 and Resident #60 were comprehensively assessed for their preference for activities and did not ensure sufficient activities were in place to meet their needs. This affected three residents (Resident #35, Resident #36, and Resident #60) out of four residents reviewed for activities. Findings Include: 1. Resident #35 was admitted on [DATE] with diagnosis of alcoholic cirrhosis of liver, Alzheimer's disease, unspecified mood disorder, dementia, major depressive disorder, anxiety disorder, wandering diseases, impulse disorder, dementia severe with agitation, cellulitis of right lower limb, hyperlipidemia, gastro-esophageal reflux disease, essential hypertension, and alcohol abuse in remission. Review of Resident #35's annual Minimum Data Set 3.0 assessment dated [DATE] revealed Section F for Preferences for Routine & Activities listed as Not Assessed. Instructions for section F state if resident is unable 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 observation, staff interview, and review of the facility policy, the facility failed to ensure the staff covered their hair exposed while working with or around food in the kitchen area. This had the potential to affect all 75 residents residing at the facility who receive food from the kitchen. Findings include: Observation on 02/24/25 at 9:21 A.M. with Dietary Manager #341 of the kitchen area and food storage area revealed Dietary Manager #341 wore his hair net on top of his head with his long dreadlocks outside of the hairnet. Dietary Manager #341, Dietary Aid #314 and Dietary [NAME] #302 had beards that were uncovered while in the kitchen. Observation on 02/24/25 at 11:26 A.M. of the food service line revealed Dietary Manager #341 wore his hair net on top of his head with his long dreadlocks outside of the hairnet while in the kitchen during meal service. Dietary [NAME] #302 was serving the food on the plates with his beard uncovered. Dietary Aid #314 was assisting in the tray line with his beard uncovered. Dietary [NAME] #302 stated they don't have beard covers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents' living environment including resident rooms, dining room, and smoking area were kept clean and homelike. This had the potential to affect all 75 residents residing in the facility. Findings include: 1. Observation and interview on 02/24/25 at 9:50 A.M. of the facility outdoor smoking area with Maintenance Assistant #412 revealed two trash cans overflowing onto the ground with styrofoam cups, papers, multiple empty cigarette packs, cigarette butts and multiple used disposable gloves. Several cigarette butts were lying on every area of the grounds. Food particles including scrambled eggs, bread, and unidentified particles were on the ground. There were two bottles of salad dressing and cheese sauce on an outside window ledge inside the smoking area courtyard. Multiple used disposable gloves were lying in different areas on the ground. Maintenance Assistant #412 stated 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, family and staff interview, and review of facility policy, the facility failed to ensure a resident met the criteria to be admitted to and reside on the secured unit This affected one (Resident #77) of three residents reviewed for abuse. The facility census was 75. Findings include: Record review for Resident #77 revealed an admission date of 02/11/25 and a discharge date of 02/17/25. Diagnoses included anoxic brain damage, intracranial injury with loss of consciousness, aphasia, encephalopathy, attention deficit hyperactivity disorder, anxiety disorder, muscle weakness, dysphagia, dysphonia, restlessness and agitation, violent behavior, traumatic brain injury (TBI), bipolar disorder, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was severely cognitively impaired. Resident #77 had no impairment to the upper or lower extremities, used a wheelchair for mobility, supervision or touch assist with eating, dependent on staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents who were dependent on staff for activities of daily living received assistance with showers and personal hygiene. This affected two (Resident #24 and #70) of three residents reviewed for activities of daily living. The facility census was 75. Findings include: 1. Record review for Resident #24 revealed an admission date of 07/25/23. Diagnosis included fibromyalgia, hemiplegia and hemiparesis following cerebral infarction, and muscle weakness. Review of the care plan dated 08/22/23 revealed Resident #24 had an activity of daily living self care performance deficit due to decline in physical and cognitive function. Interventions included bathing and showering, check nail length and trim and clean on bath day and as necessary and provide a sponge bath when a full bath or shower cannot be tolerated. Review of the quarterly Minimum Data Set (MDS) assessment 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.

Based on observation, review of the resident council meeting minutes, and interviews the facility failed to ensure the residents' environment was clean, sanitary, and was in good repair. This affected 53 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, #14, #15, #17, #18, #20, #21, #22, #23,#25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #45, #46, #47, #48, #49, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #64) of 65 residents reviewed for a homelike environment. The facility census was 65. Findings include: Review of the Resident Council Meeting notes for 04/24/24 revealed the main shower room on the first floor needed to be thoroughly cleaned. Note dated 05/28/24 revealed the first-floor shower room needed to be thoroughly cleaned. The new maintenance director (MD) is implementing a new schedule for the housekeepers. Note dated 06/26/24 stated the floor in the shower needed cleaning and repair. The new cleaning schedule was discussed, and residents will start seeing a significant difference. Observation on 07/09/24 at 8:30…

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 that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This had the potential to affect all 60 residents. The facility census was 60. Findings include: Review of personnel record for State Tested Nurse Aide (STNA) #114 revealed a hire date of 11/08/22; there was no documentation of demonstrated competencies. Review of personnel record for STNA #136 revealed a hire date of 05/25/22; there was no documentation of demonstrated competencies. Review of personnel record for STNA #165 revealed a hire date of 06/22/22 with no documentation of of demonstrated competencies. Interview on 12/06/22 at 10:02 A.M. with Human Resource Director (HR) #125 revealed that there were no documented competencies for newly hired STNAs. HR #125 stated that the Staffing Coordinator schedules the STNAs three days on the floor but verified there was no checklist or sign off. Interview on 12/07/22 at 9:28…

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 use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 60 residents residing in the facility. Findings include: Review of the posted nursing staff information and staff schedule revealed on Saturday 11/26/22 and Sunday 11/27/22 there was no RN present working in the facility on either of those dates. Interview on 12/07/22 at 9:28 A.M. with Staffing Coordinator #108 verified there was no RN coverage on 11/26/22 and 11/27/22.

Based on record review and interview, the facility failed to ensure that nurse aides were evaluated annually. This had the potential to affect all 60 residents who resided in the facility. The facility census was 60. Findings include: Review of personnel record for State Tested Nurse Aide (STNA) #119 revealed a hire date of 04/06/21 with no documentation of a completed annual evaluation. Review of personnel record for STNA #138 revealed a hire date of 02/16/87 with no documentation of a completed annual evaluation. Review of personnel record for STNA #175 revealed a hire date of 03/22/20 with no documentation of a completed annual evaluation. Interview on 12/06/22 at 10:02 A.M. with Human Resource Director (HR) #125 revealed that there were no documented annual evaluations.

Based on personnel record review and staff interview, the facility failed to provide documented evidence of dementia training for all staff. The facility had a secure unit. This had the potential to affect all 60 residents that resided in the facility. Findings Include: Review of personnel record for State Tested Nurse Aide (STNA) #114 revealed a hire date of 11/08/22 with no documentation of dementia training. Review of personnel record for STNA #136 revealed a hire date of 05/25/22 with no documentation of dementia training. Review of personnel record for STNA #165 revealed a hire date of 06/22/22 with no documentation of dementia training. Review of personnel record for STNA #827 revealed a hire date of 10/29/19 with no documentation of dementia training. Review of personnel record for STNA #828 revealed a hire date of 07/15/20 with no documentation of dementia training. Review of personnel record for STNA #829 revealed a hire date of 01/12/21 with no documentation of dementia training. Interview on 12/07/22 at 9:28 A.M. with Staffing Coordinator #108 verified there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide housekeeping services to ensure the resident environment, including bathrooms were maintained in a clean and sanitary manner. This affected 18 residents (#1, #9, #10, #15, #16, #17, #19, #27, #31, #33, #34, #38, #40, #42, #45, #46, #49, and #52) of 60 residents residing in the facility. Findings Included: Initial tour on 12/04/22 from 7:30 A.M. to 8:40 A.M. revealed concerns regarding the cleanliness and upkeep of the facility. Interviews were conducted with seven residents (Resident #10, Resident #17, Resident #19, Resident #31, Resident #40, Resident #46, and Resident #49) from 8:30 A.M. to 6:00 P.M. on 12/04/22, 12/05/22 and 12/06/22. All seven residents voiced concerns about the cleanliness of the environment. The interviews revealed that housekeeping rarely come into rooms and clean. The room cleaning schedule was not clear to the residents. They indicated there was no consistent housekeeping staff. Interview with 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, interview, taste test and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected four residents (#11, #12, #15 and #35) of four residents who were prescribed pureed diets. The facility census was 60. Findings include: Observation and interview on 12/06/22 at 11:09 AM with [NAME] #118, revealed the pureed meat sauce had pieces of meat still in the product. Dietary Manager (DM) #139 tasted the meat sauce and told [NAME] #118 to puree the meat sauce more. Cook #118 then stated, I already did the purees for lunch, so this puree isn't needed. [NAME] #118 was asked to portion out some of the already purred food. The green beans were not smooth and contained fibrous strings. DM #139 verified these finding at 11:11 A.M. on 12/06/22. The facility identified four residents, Resident #11, #12, #15 and #35 who received a pureed diet prepared by the kitchen. Review of the undated facility policy titled, Pureed Food Preparation revealed facility will prepare pureed foods in a manner that sustains nutritional value…

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 discharge planning was completed for one resident (Resident #25) out of two residents (#25 and #61) reviewed for discharge planning. The facility census was 60. Findings include: Review of Resident #25's medical record revealed and admission date of 07/29/21 with diagnoses to include but not limited to diabetes mellitus, schizophrenia, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required supervision. Review of the care of plan for Resident #25 revealed he was at the facility long term care (LTC). Review of social service note dated 07/31/21 at 10:28 A.M. revealed Resident #25 chose a full code status and discharge plans were to utilize the Home Choice Program for possible assisted living. Review of social service note dated 06/09/22 at 8:34 A.M. revealed social worker and resident had court…

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 closed record review, facility policy and procedure review and interview, the facility failed to ensure a comprehensive discharge summary was completed for Resident #61 as required. This affected one resident (#61) of two residents (Residents #25 and #61) reviewed for discharge planning. The facility census was 60. Findings include: Review of Resident #61's closed medical record revealed and admission date of 08/24/22 and a discharge date of 11/08/22 with diagnoses to include but not limited to displaced bicondylar fracture of right tibia, major depressive disorder, and personal history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/12/22 revealed the resident was moderately cognitively impaired and required supervision. Review of the plan of care dated 08/25/22 for Resident #61 revealed Resident #61 had discharge plans to go home with friends. Interventions included but not limited to all discharge planning to be documented, investigate need for special durable medical equipment (DME), home health care (HHC), lifeline, MD…

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 policy review, the facility failed to ensure weekly weights were done per physician's orders. This affected two residents (Resident #17, and Resident #40) of five residents reviewed for nutrition. The facility census was 60. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 04/21/11 and diagnoses including type two diabetes, protein calorie malnutrition, adult failure to thrive, other schizophrenia, depression, anorexia and abnormal weight loss. Review of Resident #17's annual minimum data set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact and required supervision with set up help for eating. Resident #17 had a weight loss that was not on a prescribed weight-loss regimen coded on the assessment. Review of current physician's orders revealed an order dated 10/08/21 and revised 09/07/22 for regular diet, double portions at meals, hot dogs or hamburgers at lunch and dinner; and an order written by Registered…

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 insure medications were properly stored. This affected three residents (#12, #21 and #49) of three residents review for medications not properly stored. The facility census was 60. Findings Included: An initial tour of this facility on 12/04/22 from 8:30 A.M. to 9:15 A.M. revealed loose pills were observed on the floor in two different rooms, the room for Resident #12 and Resident #21 and the room for Resident #49. Upon entrance into Resident #12 and Resident #21 room at 8:40 A.M. a small round white pill was observed laying on the floor close to the entrance of the bathroom. Interview with Licensed Practical Nurse (LPN) #177 on 12/04/22 verified the pill was in the room on the floor which she stated 'looked like Remeron. LPN #177 returned back to the room after looking up the pill and stated it was Remeron. Neither Resident #12 or Resident #21 were on Remeron. At 9:10 A.M. observation of Resident 49's room revealed two pills on the floor next to the baseboard by the door. Interview with LPN #144 at 9:15 A.M. verified two…

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

Based on observation and interview, the facility failed to ensure a dignified dining experience for all residents. This affected 13 (Residents #3, #7, #16, #18, #36, #48, #56, #62, #72, #75, #81, #91 and #92) of 86 residents that received meals prepared in the facility kitchen. The facility census was 88, Residents #21 and #90 received nothing by mouth. Findings include: Interview on 09/23/19 at 08:20 A.M. with [NAME] #9 revealed dessert was sometimes served on styrofoam plates. Observation during meal service for lunch on 09/23/19 from 11:30 A.M. through 11:47 A.M. revealed Residents #3, #7, #16, #18, #36, #48, #56, #62, #72, #75, #81, #91 and #92 were served cake portioned out onto a six-inch styrofoam plate instead of a china plate. This was verified by State Tested Nurse Aide ( STNA) #10 at 11:35 A.M. Interview with Registered Dietitian (RD) #85 on 09/25/19 at 10:51 A.M. revealed she had just started three weeks ago. RD #85 was not aware desserts were served on styrofoam plates and confirmed all food should be served on china plates.

Based on observation and interview the facility failed to ensure outdated insulin vials were disposed of. This affected four (Resident #64, Resident #50, Resident #6, and Resident #11) of 11 residents residing on the Grand Heritage Unit who were reviewed for insulin use. The facility census was 88. Findings include: Observation of two medication carts (Grand Heritage Medication Cart #1 and Grand Heritage Medication Cart #2) on 09/24/19 at 8:10 A.M. revealed four vials of outdated insulin. Observation of the Grand Heritage Medication Cart #1 revealed two vials of insulin that were outdated. One vial of Novolog insulin belonging to Resident #6. The vial was dated as opened on 08/23/19. The second vial of Novolog insulin which belonged to Resident #11 was dated as opened on 08/24/19. On 09/25/19 at 10:05 A.M. Licensed Practical Nurse (LPN) #68 confirmed Novolog insulin was only good for 30 days after opening. LPN #68 verified the insulin vials should have been disposed of. Observation of the Grand Heritage Medication Cart #2 revealed one vial of outdated Novolog insulin belonging 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 observation, interview and policy review the facility failed to ensure equipment and food preparation areas were maintained in a clean and sanitary manner, and foods were dated when opened and properly stored and labeled. This had the potential to affect 86 of 88 residents whose meals were prepared in the kitchen. Residents #21 and #90 received nothing by mouth. Findings include: Observations during initial tour of the kitchen on 09/23/19 from 8:12 A.M. through 8:20 A.M. with Dietary Manager (DM) #63 revealed concerns with cleanliness and storage. There was dried food residue inside the microwave oven. There was food residue, a braising pan and a ball of tin foil under the three-compartment sink. Bins used for flour, sugar and thickener were not labeled and dated. There were unlabeled, undated, opened bags of garlic bread, crepes, broccoli and biscuits in the walk-in freezer. There was mold on the wall behind the dish machine. On 09/23/19 at 8:20 A.M. DM #63 verified the observations above and said the kitchen could be cleaner. DM #63 said the dietary department 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 maintain a clean and sanitary environment. This affected 20 residents (Residents #1, #8, #13, #15, #17, #23, #24, #31, #35, #40, #42, #51, #54, #55, #63, #65, #66, #67, #84 and #193) currently residing on the Arcadia Unit and Residents #6, #11, #14, #22, #26, #29, #38, #60, #70 and #92. The facility census was 88. Findings include: 1. Observation on the Arcadia Unit (secured unit) during the lunch meal on 09/24/19 between 11:55 A.M. and 12:10 P.M. revealed the following observations. There were multiple water stained ceiling tiles, three tables with large red stains, one table with a ripped table cloth, and the walls of the dining area were badly scuffed with noticeable areas where the paint was peeling. On 09/23/19 at 12:12 P.M. Licensed Practical Nurse (LPN) #76 confirmed 20 residents were eating in the dining room where the walls were scuffed with paint was peeling, and some of the them were seated at stained tables. 2. On 09/26/19 between 9:35 A.M. and 9:44 A.M. an environmental tour was conducted with 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 observation, interview, and record review the facility failed to provide water flushes as ordered by the physician for Resident #90 and failed to ensure call lights were within reach for Resident #25 and Resident #85. This affected one (Resident #90) of two residents reviewed for tube feeding administration and two (Residents #25 and #85) of two residents reviewed for call lights. The facility census was 88. 1. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition and presence of a gastrostomy tube (tube into the stomach). Review of the physician order for Resident #90, dated 09/03/19, revealed Resident #90 was to receive water flushes at 40 milliliters per hour (ml/hr). Observation on 09/25/19 at 04:16 P.M. revealed Resident #90's tube feeding pump was set to deliver the water flush at 70 ml/hr. Registered Nurse (RN) #72 was interviewed on 09/25/19 at 04:18 P.M. and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure catheter care was provided every shift. This affected two (Resident #16 and Resident #68) of eight residents reviewed for catheter care. The facility census was 88. Findings include: 1. Resident #16 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] from the hospital. Diagnoses included hematuria, indwelling urethral catheter, dementia, neurogenic bladder and obstructive uropathy. Review of the plan of care dated 03/15/19 revealed the resident had an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. Interventions included: change urinary collection bag as needed; change catheter per physician's order; and catheter care. Review of the Minimum Data Set Assessment (MDS) 3.0 dated 09/13/19 revealed the resident was cognitively intact and required extensive assistance most activities of daily living including toilet use and personal hygiene. Review of the Medication Administration Record (MAR)…

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 policy review, the facility failed to ensure consistent use of adaptive equipment for two (Resident #22 and #43) of ten residents reviewed for adaptive equipment. The facility census was 88. Findings include: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse and high blood pressure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact and was independent for eating with set up only. Review of the meal ticket revealed Resident #22 should have built-up utensils and a three-compartment plate for meals. Observation of the lunch meal on 09/25/19 revealed Resident #22 was not provided with built-up utensils. This was verified by STNA #14 at 12:06 P.M. 2. Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia, seizures and psychosis. Review of the MDS dated [DATE] revealed Resident #43 was severely cognitively impaired 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 facility policy the facility failed to ensure proper hand hygiene and wound cleansing was implemented during Resident #85's dressing change. This affected one (Resident #85) of seven residents reviewed for wound care. The facility census was 88. Findings include: Resident #85 was admitted to the facility on [DATE] with cumulative diagnoses including a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat, may be exposed) psychosis and anxiety disorder. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had a stage III pressure ulcer. Review of physician orders dated 09/05/19 revealed an order to cleanse the wound to the right upper distal thigh with normal saline, pat dry, apply collagen (healing agent) and cover with a foam dressing daily at bedtime. Observation on 09/25/19 at 3:10 P.M. of wound care for Resident #85 by Licensed Practical Nurse (LPN) #65 revealed during the dressing change LPN #65 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 observation, interview and policy review the facility failed to ensure the smoking policy was adhered to for Resident #22. This affected one (Resident #22) of eight residents (#11, #22, #29, #36, #62, #69, #77 and #85) reviewed for smoking. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included, major depressive disorder, alcohol abuse and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact and required supervision for most activities of daily living. Review of Resident #22's care plan dated 05/21/19 and Resident 22's smoking recent smoking assessment dated [DATE] revealed Resident #22 required supervision and a smoking apron to ensure safety during smoking. Review of the smoking assessments for Residents #11, #29, #36, #62, #69, #77 and #85 revealed none of them were dependent smokers and did not require the use of a smoking apron. Observation on 09/25/19 at 1:10 PM…

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.