Avenue At North Ridgeville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident allergy was identified for a physician ordered medication during the monthly medication regimen review. This affected one (#95) of three residents reviewed for medication allergies. The facility census was 100.Review of the medical record for Resident #95 revealed an admission date of 05/06/21. Diagnoses included type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #95's allergy alert profile dated 05/26/21 revealed the resident had allergies to metformin, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. On 08/27/24 an allergy to Ativan was added. The allergy to metformin was noted as unknown severity.Review of Resident #95's care plan revealed the resident had allergies to Abilify,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, pharmacist interviews, and policy review, the facility failed to ensure a resident was not administered a medication with a noted allergy without clarification from the physician. This affected one (#95) of three residents reviewed for medication allergies. The facility identified 67 residents with medication allergies. The facility census was 100.Review of the medical record for Resident #95 revealed an admission date of 05/06/21. Diagnoses included type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #95's allergy alert profile dated 05/26/21 revealed the resident had allergies to metformin, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. On 08/27/24 an allergy to Ativan was added. The allergy to metformin was noted as unknown severity.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, hospital documentation review, and staff interview, the facility failed to ensure surgical wound and wound drainage care was provided as ordered by a physician following re-admission to the facility. This affected one (#52) of three residents reviewed for wounds. The facility census was 93. Findings include: Review of Resident #52's medical record identified admission to the facility occurred on 11/16/23 with medical diagnoses including bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs. Further review of the medical record revealed Resident #52 required hospitalization from 04/29/24 through 05/07/24 for a scrotal abscess that required incision and drainage surgery. Review of Resident #52's hospital discharge documentation dated 05/07/24 revealed physician orders, under the section for drain and tube care, for the resident to have a nurse change the Kerlix dressing (antimicrobial rolled dressing) twice a day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, hospital documentation review, and staff interview, the facility failed to ensure resident re-admission and skin assessments were accurate. This affected one (#52) of three residents reviewed for wounds. The facility census was 93. Findings include: Review of Resident #52's medical record identified admission to the facility occurred on 11/16/23 with medical diagnoses including bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs. Further review of the medical record revealed Resident #52 required hospitalization from 04/29/24 through 05/07/24 for a scrotal abscess that required incision and drainage surgery. Review of Resident #52's hospital discharge documentation dated 05/07/24 revealed physician orders, under the section for drain and tube care, for the resident to have a nurse change the Kerlix dressing (antimicrobial rolled dressing) twice a day with wet to dry and maintain a Penrose drain (a soft,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, policy review, and review of a self-reported incident, the facility failed to ensure Resident #89 was treated with respect and dignity during care. Additionally, the facility failed to ensure privacy and dignity was provided to Resident #02 while toileting, and failed to ensure indwelling urinary catheter drainage bags were covered in a dignified manner for Residents #39 and #56. This affected four (Residents #89, #02, #39, and #56) of seven residents reviewed for activities of daily living and dignity. The facility census was 96. Findings include: 1. Review of the medical record for Resident #89 revealed an admission date of 03/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, iron deficiency anemia, and muscle weakness. Review of Resident #89's Minimum Data Set (MDS) 3.0 admission assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility failed to complete a Minimum Data Set (MDS) 3.0 significant change assessment for a resident who sustained a significant decline in functional abilities following a fall with upper extremity fracture. This affected one (Resident #20) of ten residents reviewed for accuracy of assessments. The facility census was 96. Findings include: Review of the medical record for Resident #20 revealed an admission date of 06/02/22. Medical diagnoses included Sjogren syndrome, lack of coordination, muscle weakness, and a displaced fracture of the surgical neck of the left humerus. The resident sustained a fall with a left humerus fracture at the facility on 02/22/24. Review of an incident report dated 02/22/24 at 5:35 P.M. revealed Resident #20 sustained a fall after attempting to get up unassisted to walk to the bathroom. The resident landed on her left shoulder and did not hit her head. The nurse on duty was present outside of Resident #20'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 interview, record review, and policy review, the facility failed to ensure a baseline care plan was developed and a summary provided to Resident #100 and/or their representative. The facility also failed to ensure a summary of Resident #111's baseline plan of care was provided to the resident and/or their representative. This affected two (Residents #100 and #111) of four residents reviewed for care planning. The facility census was 96. Findings include: 1. Review of the medical record for Resident #100 revealed an admission date of 03/03/24. Medical diagnoses included cerebrovascular accident (stroke) with residual right sided weakness, type II diabetes mellitus, and frequent falls. Resident #100 was transferred to a local hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) 3.0 Medicare 5-day and discharge return not anticipated assessment, dated 03/07/24, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of a 00, indicating severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility failed to ensure resident care plans were updated to reflect individualized and necessary components of the residents' care. This affected two (Residents #20 and #94) of ten residents reviewed for care plans. The facility census was 96. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 06/02/22. Medical diagnoses included Sjogren syndrome, lack of coordination, muscle weakness, and a displaced fracture of the surgical neck of the left humerus. The resident was recorded to have had a fall with fracture with an overnight hospitalization from 02/23/24 to 02/24/24. The resident had a second hospitalization for pneumonia from 02/27/24 to 03/03/24. Review of the Minimum Data Set (MDS) 3.0 Medicare 5-day assessment dated [DATE], revealed Resident #20 to have a Brief Interview for Mental Status (BIMS) score of eight, indicative of moderately impaired cognition. Review of the incident report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and policy review, the facility failed to remove an indwelling urinary catheter as ordered and failed to provide justification for the continued use of the indwelling urinary catheter. This affected one (Resident #20) of one resident reviewed for urinary catheters. The facility census was 96. Findings include: Review of the medical record for Resident #20 revealed an admission date of 06/02/22. Medical diagnoses included Sjogren syndrome, lack of coordination, muscle weakness, and a displaced fracture of the surgical neck of the left humerus. The resident sustained a fall with a left humerus fracture at the facility on 02/22/24. Review of an incident report dated 02/22/24 at 5:35 P.M. revealed Resident #20 had a hospitalization for pneumonia from 02/27/24 to 03/03/24. The resident returned to the facility on [DATE]. Review of Resident #20's interdisciplinary progress notes revealed a noted dated 03/03/24 at 12:30 P.M. indicating Resident #20 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and personnel file review, the facility failed to ensure all State Tested Nursing Assistants met the competency verification requirements. This had the potential to affect all residents residing in the facility. The facility census was 102. Findings include Interview on [DATE] at 12:00 P.M. with State Tested Nursing Assistant (STNA) #240 revealed she had worked with Dietary Aide (DA) #200 numerous times and DA #200 performed tasks of an STNA. DA #200 had been at the facility for approximately a year and a half and had not taken the STNA certification test. Telephone interview on [DATE] at 1:50 P.M. with STNA #230 revealed DA #200 had been employed at the facility for a long time and was allowed to work as and STNA without having taken the STNA certification test. STNA #230 stated the Administrator was aware DA #200 was not state tested and allowed DA #200 to continue to work as an STNA. Telephone interview on [DATE] at 2:29 P.M. with DA #200 revealed she had been employed at the facility for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure care conferences were held in a timely manner and residents or their representatives were included in their care conferences. This affected one (#105) of three residents reviewed for care planning. The facility census was 103. Findings include: Review of Resident #105's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia, muscle weakness, insomnia, and muscle weakness. The resident expired in the facility on [DATE]. Review of Resident #105's Minimum Data Set (MDS) 3.0 assessments dated [DATE], [DATE], and [DATE], revealed the resident was assessed with severe cognitive impairment. Further review of Resident #105's medical record revealed the resident's daughter was his power of attorney for care and finances. Review of Resident #105's plan of care, initiated on [DATE], revealed the resident had the right to make lifestyle choices. 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered resulting in a significant medication error. This affected one (#104) of three residents reviewed for medication administration. The facility census was 103. Findings include: Review of Resident #104's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, presence of cardiac pacemaker, cerebral infarction, depression, heart disease, weakness, and shortness of breath. Review of Resident #104's plan of care, dated 11/11/22, revealed the resident had diabetes with a goal of no complications. Interventions included blood sugar to be checked as ordered and medications as ordered. Review of Resident #104's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/23, revealed the resident was assessed as cognitively impaired and required assistance of one staff member for a majority 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 and interview, the facility failed to ensure a resident's central line intravenous (IV) catheter was maintained per the facility policy. This affected one (#87) of two residents reviewed for having IV catheters. The facility census was 68. Findings include: Review of Resident #87's medical record revealed the resident was originally admitted on [DATE] and had a readmission on [DATE] with diagnoses including acute cholecystitis, hemiplegia, and diabetes. Review of the physician orders for Resident #87's dated 06/07/23, revealed the resident had a [NAME] vascular central intravenous (IV) access catheter to the chest wall. The orders revealed no other documentation for the central line to be maintained and/or cared for by staff. Review of the hospital's discharge notes for Resident #87 dated 08/08/23, revealed the resident was discharged to the facility with a double lumen central line catheter in her right upper chest wall and to continue the IV care per nursing protocol. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, the facility failed to ensure residents had treatment orders for wounds and failed to ensure dressing changes were completed as ordered. This affected two (Residents #50 and #96) of three sampled residents. The facility census was 72. Findings include: 1. Record review revealed Resident #96 was admitted to the facility on [DATE], with diagnosis including sepsis from a pressure ulcer, end stage renal disease, diabetes, pulmonary embolism, colostomy, gastrostomy and tracheostomy. Review of Wound Physician #370's progress notes revealed he evaluated Resident #96's wounds in the facility on 07/21/23 at 7:25 A.M. The notes documented Resident #96 was admitted the day prior, 07/20/23, with physician orders for a wound vacuum to the sacral area. Wound Physician #370 documented the wound vacuum would be contraindicate, due to eschar, bleeding and possible bone involvement. There was an order to pack the coccyx wound with Dakin's soaked gauze (3 rolls) for a wet…

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 X-ray results were communicated to the physician. This affected one (Resident #97) of three sampled residents. The facility census was 72. Findings include: Record review revealed Resident #97 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, congestive heart failure, atrial fibrillation and history of falling. Review of the progress notes dated 07/27/23 at 6:26 A.M. documented the nurse was notified by the State Tested Nursing Assistant (STNA) that Resident #97 was found on lying on the right side on the floor near the bathroom. Resident #97 was complaining of pain to the right wrist. The physician was notified and an X-ray was ordered for the wrist. Review of the X-Ray report dated 07/27/23 at 9:47 P.M. revealed Resident #96 had an acute nondisplaced fracture of the distal radius with intra-articular extension to the radiocarpal joint. Carpal alignment remains normal. There is adjacent soft tissue…

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, review of weekly cleaning logs, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 61 residents who received meals in the facility. The facility identified Resident #37 as receiving nothing by mouth. The facility census was 62. Findings include: Observation of the kitchen during the initial tour with Dietary Manager (DM) #518 on 02/13/23 at 6:35 P.M. revealed three large bins with brown sugar, white sugar, and flour all containing a scoop lying in the bin. The under tray line freezer across from the fryer contained a bag of chicken breasts which was open. There was spilled food and food particles in the back of freezer. The under tray line cooler revealed tray of uncovered open hot dogs without a label/date. The walk-in cooler revealed uncovered prepared dish of cottage cheese with no label or date. Observation of walk-in freezer revealed open bags of fish and burgers and two dished up uncovered bowls of ice cream with no label or date. Observation under the three…

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, observation, and staff interview, the facility failed to ensure residents were treated with dignity at meal service. This affected one resident (#35) observed during meal service. The facility identified one resident who required pureed meals. The facility census was 62. Findings include: Review of Resident #35's medical record revealed an admission date of 02/12/22. Diagnoses included Alzheimer's disease, psychotic disorder with delusions, dysphasia, and aphasia. Review of Resident #35's quarterly Minimum Data Set (MDS) assessment, dated 01/03/23, revealed the resident had a low cognitive function. The resident required an extensive assist with eating. Review of Resident #35's most recent care plan revealed the resident was downgraded to a puree and honey thick liquid diet. Review of Resident #35's physician order dated 01/05/23 revealed the resident was to be fed for all meals and snacks due to aspiration prevention. On 12/12/22 a regular, pureed diet was ordered. Observation on 02/14/23 at 8:28 A.M. revealed all residents in the memory care unit were…

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

Based on review of a medical record request document, staff interview and review of facility policy, the facility failed to provide copies of the medical record within two working days one (#166) of one resident reviewed for medical record requests. The facility census was 62. Findings include: Review of the medical record for Resident #166 revealed an admission date of 01/12/23 and a discharge date of 01/18/23. Diagnoses included chronic obstructive pulmonary disease, history of myocardial infarction, type two diabetes mellitus, hypertension atrial flutter, systolic heart failure, malignant neoplasm of part of the right bronchus or lung, and hyperlipidemia. Review of a medical record request document revealed medical records were requested by Resident #166 on 02/02/23. Interview on 02/16/23 at 11:31 A.M. the Director of Nursing (DON) revealed the facility had received a letter from the resident requesting medical records within the next 30 days. The DON stated the record request had been forwarded to their corporate office. The DON revealed the medical records had not yet been sent…

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 complete a comprehensive care plan for urostomy care. This affected one (#62) of one resident reviewed for urostomy care. The facility census was 62. Findings include: Review of medical record revealed Resident #62 was admitted on [DATE] with diagnoses including obstruction of duodenum (part of the intestine), malignant neoplasm of the bladder, type II diabetes mellitus, and malignant neoplasm of lower lobe bronchus or lung. The resident had a urostomy and provided all the care for the ostomy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 62 was cognitively intact. Resident #62 required supervision for toileting. The assessment revealed Resident #62 had an ostomy. Review of care plan dated 01/23/23 revealed Resident #62 had no care plan addressing urostomy care, monitoring, or ensuring adequate supplies. Interview with Licensed Practical Nurse (LPN) #531 on 02/15/23 at 4:51 P.M. verified Resident #62'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 medical record review, observation, family interview and staff interviews, the facility failed to provide appropriate communication tools for one (#9) out of one resident reviewed for communication needs. The census was 62. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, diabetes mellitus type 2, convulsions, intellectual disabilities, and schizophrenia. Review of the annual Minimum Data Set (MDS) assessment, dated 11/21/22, revealed Resident #9 had severe cognitive impairment and no verbal communicative ability. Resident #9 was determined to require extensive assistance from one to two persons for bed mobility, locomotion, dressing, eating and personal hygiene. Resident #8 was totally dependent for toileting and transfers. Review of the care plan dated 12/09/22, revealed Resident #9 had a cognitive loss. Interventions included staff anticipation of needs. The care plan 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.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure wound treatments were completed per physician orders. This affected one (#1) of one resident reviewed for wounds. The facility census was 62. Findings include: Medical record review revealed Resident #1 had an admission date of 05/26/21. Diagnoses included transient cerebral ischemic attack, Type two diabetes mellitus with diabetic nephropathy, mild protein calorie malnutrition, schizoaffective disorder bipolar type, anxiety disorder, dysphagia, major depressive disorder, obsessive compulsive disorder, atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/15/22, revealed the resident had impaired cognition. Review of a skin assessment, dated 02/10/23, revealed the resident had a diabetic ulcer on the right heel measuring 0.3 centimeters (cm) in length by 0.4 cm in width by 0.1 cm in depth. The wound had no odor, no exudate, no tunneling and no undermining. The wound bed was 100 percent pink tissue. The…

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

Based on record review, staff interview, and family interview, the facility failed to replace a resident's missing glasses. This affected one (#22) of two residents reviewed for missing items. The facility census was 62. Findings include: Review of Resident #22's medical record revealed an admission date of 03/15/22. Diagnoses included vascular dementia, cerebrovascular disease, amyloidosis, chronic kidney disease stage three, and spinal stenosis. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment, dated 01/19/23, revealed the resident had a low cognitive function. The resident had no noted behaviors. Resident #22 required an extensive assistance for all activities of daily living except eating which was supervised. Review of Resident #22's most recent care plan revealed the resident will have optimal visual ability due to glaucoma and required glasses. Interventions included the resident was to be encouraged to wear the glasses, to have the glasses readily available and the glasses were to be kept clean. Review of Resident #22's medical and social service notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and observation, the facility failed to change oxygen tubing for the oxygen concentrator and tubing for the aerosol nebulizer for one (#8) of three residents reviewed for respiratory therapy. The facility census was 62. Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included hypertension, heart disease, heart failure, respiratory failure and chronic obstructive pulmonary disease. The care plan dated 12/17/22 revealed Resident #8 was at risk for respiratory issues related to his diagnoses of chronic obstructive pulmonary disease and cardiac diseases. Interventions included to administer oxygen as ordered. Observation on 02/14/23 at 2:07 P.M. of Resident #8's room revealed the oxygen tubing for the oxygen concentrator was dated for 02/05/23 . The tubing connected to the nebulizer was dated 01/26/23. The resident was currently utilizing the oxygen tubing attached t o the concentrator via a nasal…

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 medical records, review of guidelines from the National Library of Medicine/National Institute of Health, observation, staff interview and review of facility policy, the facility failed to ensure medications were administered per physician orders. This affected three (#166, #26, #22) of seven residents reviewed for medication administration. The facility census was 62. 1. Review of the medical record for Resident #166 revealed an admission date of 01/12/23 and a discharge date of 01/18/23. Diagnoses included chronic obstructive pulmonary disease, history of myocardial infarction, type two diabetes mellitus, hypertension atrial flutter, systolic heart failure, malignant neoplasm of part of the right bronchus or lung, and hyperlipidemia. Review of the five day Minimum Data Set (MDS) assessment, dated 01/17/23, revealed the resident had intact cognition. Review of a nurses noted dated 01/12/23 at 2:34 P.M. revealed Resident #166 was admitted to the facility from the hospital. Review of physician orders for 01/18/23 revealed the resident was ordered MS Contin 15 extended…

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 immunization documentation, staff interview and review of facility policy, the facility failed to ensure a resident was offered a pneumococcal vaccination. This affected one (#10) of five residents reviewed for immunizations. The facility census was 62. Findings include: Medical record review revealed Resident #10 had an admission date of 07/26/21. Diagnoses included Alzheimer's disease with late onset, depression and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/23, revealed the resident had impaired cognition. Review of the immunization record revealed no documentation the resident had been offered or had refused a pneumococcal immunization. Interview on 02/16/23 at 11:38 A.M., Registered Nurse (RN) #609 verified there was no documentation in the medical record the resident had been offered or had refused a pneumococcal immunization. Review of the facility policy titled Influenza and Pneumococcal Immunization Policy, last revised 10/2022, revealed based upon assessment and the physician's recommendations, the resident will be…

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