Diplomat Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the facilities Self-Reported Incidents (SRI) and investigations, review of policy, and medical record review, the facility failed to timely report an injury of unknown origin to the State Survey Agency and failed to complete self-report incident investigations within five days of the required timeline. This affected two (Residents #67 and #78) of seven residents reviewed for abuse. The facility census was 101. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 09/01/22. Diagnoses included senile degeneration of the brain and dementia with agitation. Resident #67 was on hospice services for senile degeneration of the brain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood and was unable to participate in cognitive assessment. Resident #67 was dependent on staff for toileting hygiene, bed mobility, dressing, and transfers. Review of the nursing progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of facility self-reported incident (SRI) investigation, review of facility policy, hospice record review, and medical record review, the facility failed to thoroughly investigate a resident's injury of unknown origin. This affected one (Resident #67) of seven residents reviewed for abuse. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admission date of 09/01/22. Diagnoses included senile degeneration of the brain and dementia with agitation. Resident #67 was on hospice services for senile degeneration of the brain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was rarely understood and was unable to participate in cognitive assessment. Resident #67 was dependent on staff for toileting hygiene, bed mobility, dressing, and transfers. Review of the nursing progress note dated 11/21/24 at 7:39 A.M. revealed during incontinence care at approximately 12:30 A.M., a caregiver observed…

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

Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure physician orders were implemented to promote healing of a resident's wound to his foot. This affected one (Resident #67) of three residents reviewed for wounds. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admission date of 09/01/22. Diagnoses included senile degeneration of the brain, dementia with agitation, generalized muscle weakness, and muscle wasting and atrophy. Review of the annual Minimum Data Set (MDS) assessment, dated 10/14/24, revealed Resident #67 had unclear speech, was rarely/never understood or understands, and was moderately cognitively impaired. Resident #67 was dependent on staff for lower body dressing, putting on /taking off footwear, personal hygiene, and bed mobility. Review of the wound care progress note for Resident #67 dated 10/17/24 completed by Wound Care Certified Nurse Practitioner (CNP) #303 revealed Resident #67 was being seen for follow up wound care services. The lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and medical record review, the facility failed to ensure a resident received appropriate assistance during incontinence care to prevent accidents. This affected one (Resident #67) of three residents reviewed for accidents. The facility census was 101. Findings include: Review of the medical record for Resident #67 revealed an admission date of 09/01/22 and diagnoses including senile degeneration of the brain, dementia with agitation, and muscle wasting and atrophy. Resident #67 was on hospice services for senile degeneration of the brain. Review of the plan of care initiated 06/06/23 revealed Resident #67 had the potential for falls. Interventions included two staff members for incontinence care and repositioning (added 11/01/24), get resident up in chair when restless, perimeter mattress, occupational therapy evaluation, observe frequently, and place in a supervised area when out of bed. Review of the Fall Risk assessment dated [DATE] revealed Resident #67 was at high risk for falls.…

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 ensure Resident #11, who was cognitively impaired, dependent on staff for incontinence care/management and had moisture associated dermatitis (MASD) was provided necessary incontinence care to promote optimal skin integrity and prevent additional complications from the MASD. This affected one resident (#11) of three residents reviewed for incontinence care. The facility census was 101. Findings include: Record review for Resident #11 revealed an admission date of 07/21/20 with diagnoses including cerebral infarction due to occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, dementia, and muscle weakness. Review of the care plan for Resident #11 dated 06/06/23 revealed Resident #11 experienced bladder incontinence related to hemiplegia /hemiparesis following cerebral infarction. Interventions included to provide…

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, facility policy review, and interview, the facility failed to ensure resident-to-resident physical altercations were reported the State Agency as required. This affected ten Residents (#28, #30, #39, #48, #57, #58, #69, #77, #85, and #357) of 39 residents who reside on the secured memory care unit. The facility census was 99. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dementia with behavioral disturbance, major depressive disorder, delusional disorders, and wandering. Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #30 had Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #30 was unable to complete the assessment. Resident #30 had memory problems, severely impaired decision making, inattention, and disorganized thinking. Review of Resident #30's progress note dated [DATE] at 7:32 P.M. 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 individualized cared planned interventions were in place to prevent resident behaviors resulting in resident to resident altercations on the secured memory care unit (SCMU). This affected nine Residents (#28, #30, #39, #48, #57, #58, #69, #77, and #85) of ten residents reviewed for behavioral health services. The facility census was 99. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 08/18/22 and diagnoses including Alzheimer's disease, dementia with behavioral disturbance and agitation, major depressive disorder, schizoaffective disorder, psychotic disorder, anxiety disorder, and altered mental status. Review of the Medicare MDS Annual assessment dated [DATE] revealed Resident #28 had a BIMS score of 99 indicating Resident #28 was unable to complete the assessment. Resident #28 had memory problems, severely impaired decision making, and disorganized thinking. There were no behaviors noted. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interview the facility failed to ensure Resident #10 was assisted with eating his meal in a timely manner. This affected one resident (Resident #10) out of three residents reviewed for meal assistance. The facility census was 99. Findings include: Resident #10 was admitted on [DATE] with diagnoses including traumatic brain injury with anoxic brain injury, psychosis, depression, mixed receptive-expressive language disorder, mood and personality disorder, encephalopathy, anxiety, dementia with behaviors, dysphagia (difficulty swallowing), and cognitive communication deficit. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 had severe cognitive impairment, and he needed substantial/maximal assistance with eating meals. Resident #10's plan of care edited on 09/25/24 indicated Resident #10 had and increased nutrition/hydration risk related to a diagnosis of traumatic brain injury, and history of weight loss and insertion of a gastronomy tube,…

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

Based on observation, interview, and policy review, the facility failed to secure medications appropriately. This had the potential to affect all 99 residents residing in the facility. Findings include: Observation on 10/07/24 at 2:00 P.M. revealed a medication cart on the third floor had 14 unsecured unidentified medications. Interview during the observation, Licensed Practical Nurse (LPN) # 528 verified the observations stating loose medications should be discarded. Observation on 10/07/24 at 2:09 P.M. revealed a medication cart on the third floor had 19 unsecured unidentified medications. Interview during the observation, LPN #535 verified the observations stating loose medications should be discarded. Observation on 10/07/24 at 2:29 P.M. revealed a medication cart on the first floor had 9 unsecured unidentified medications. Interview during the observation, LPN #538 verified the observations stating loose medications should be discarded. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated 2024 noted staff should ensure that…

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

Based on record review, observations, and interview, the facility failed to sanitize blood sugar glucometers appropriately. This had the potential to affect five residents (Resident #20, #21, #37, #80, and #95) of 13 residents who required blood sugar testing and monitoring. Findings include: Observations on 10/07/24 at 1:42 P.M. revealed Licensed Practical Nurse (LPN) #538 was checking a blood glucose level for Resident #37 with a glucometer. LPN #538 placed the glucometer in the top drawer of the medication cart without sanitizing. Interview on 10/07/24 at 1:52 P.M., LPN #538 verified that she did not sanitize the glucometer and preceded to sanitize the glucometer with an alcohol wipe. LPN #538 stated the bleach wipes were too strong to use for cleaning. LPN #538 revealed she was assigned to complete blood sugar checks with a glucometer for Resident #20, #21, #37, #80, and #95. a. Review of medical record for Resident #20 noted an admission date of 04/19/11. Diagnoses included unspecified dementia and type two diabetes mellitus. Resident #20 had intact cognition. 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, interview, and record review the facility failed to ensure medications were not left unattended in resident rooms. This affected one of three residents (Resident #43) reviewed for medication storage. The census was 101. Findings Include: Review of the medical record for Resident #43 revealed an admission date of 09/21/23. Diagnoses included congestive heart failure, hypertension, chronic obstructive pulmonary disease, and acute kidney disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #43 had impaired cognition. Review of Resident #43's physician orders for July 2024 revealed orders for aspirin 81 milligrams (mg) daily, Farxiga (antidiabetic) 10 mg tablet, isosorbide mononitrate (for chest pains) tablet extended release, every 24 hours, 30 mg tablet, Lisinopril-Hydrochlorothiazide (for blood pressure) 20-25 mg tablet daily and Symbicort HFA aerosol inhaler (for pulmonary disease) 160-4.5 microgram (mcg)/actuation, two puffs twice a day. 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 record review, interview, facilities self reported investigation review, and facilities policy review, the facility failed to timely report an allegation of physical abuse to the State Agency for Resident #85. This affected one (Resident #85) of three residents reviewed for abuse. The facility census was 100. Findings include: Review of the medical record for Resident #85 revealed an admission date of 07/21/20 with diagnoses including aphasia (difficulty speaking), diabetes mellitus and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had moderately impaired cognition. She had adequate hearing, clear speech, was able to understand others and was able to make herself understood. Review of the facility Self-Reported Investigation (SRI) #245035 dated 03/10/24 revealed the facility was investigating the potential for physical abuse to Resident #85 by State Tested Nurse Aide (STNA) #204. Findings were as follows: -Statement dated 03/10/24 from the…

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

Based on observation, review of cleaning schedules, and interview the facility failed to ensure a clean and sanitary environment for residents. This affected Residents #7, #32, and #58 and had the potential to affect all residents. The facility census was 101. Findings include: Observation and interview on 03/06/24 at 11:18 A.M. revealed the bottom drawer of Resident #58's dresser had no bottom and the sides of the drawer were broken. The floor along the wall had dust, pieces of paper and food particles. In the bathroom, there was a hole behind the toilet and the sink had soap scum around the edges. This was verified by Licensed Practical Nurse (LPN) #207 at 11:21 A.M. on 03/06/24. Observation on 03/06/24 at 11:24 A.M. of Resident #32's bathroom revealed feces on the wall. This was verified with LPN #207 at the time of the observation. Observation on 03/06/24 at 11:26 A.M. revealed Resident #7's bathroom had scuff marks on the floor, there was grime along the baseboard of the wall and the sink had soap scum around the basin. This was verified by LPN #207 at the time 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 interview, record review and facility policy review the facility failed to update Resident #118's comprehensive fall prevention care plan to ensure fall prevention interventions were implemented. This affected one resident (Resident #118) of three residents reviewed for falls. The facility census was 117 residents. Findings include: Review of Resident #118's closed medical record revealed an admission date of [DATE] with diagnoses including dementia with other behavioral disturbance, diabetes, hyperlipidemia, epilepsy, hypertension, encephalopathy and hypothyroidism. Resident #118 expired in the facility on [DATE]. Review of Resident #118's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #118 was cognitively impaired, totally dependent on two staff for bed mobility and transfer and totally dependent on one staff for personal hygiene. Resident #118 had one fall without injury and two falls with minor injury since admission. Review of an admission fall risk assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician's orders were faxed timely to receiving providers for prompt scheduling of services. This affected one resident (Resident #118) of three residents reviewed for accidents. The facility census was 117 residents. Findings include: Review of Resident #118's closed medical record revealed an admission date of [DATE] with diagnoses including dementia with other behavioral disturbance, diabetes, hyperlipidemia, epilepsy, hypertension, encephalopathy and hypothyroidism. Resident #118 expired in the facility on [DATE]. Review of Resident #118's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #118 was cognitively impaired, was totally dependent on two staff for bed mobility and transfer and was totally dependent on one staff for personal hygiene. Resident #118 had one fall without injury and two falls with minor injury since admission. Review of a nurses' note dated [DATE] at 5:12 P.M. authored by Licensed…

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 proper wound treatment and pressure relieving interventions were implemented timely for Resident #18's unstageable pressure ulcer. This affected one (Resident #118) out of three residents reviewed for pressure ulcers. The facility census was 117. Findings include: Review of the medical record revealed Resident #118 was admitted on [DATE] with diagnoses including dementia, diabetes mellitus and hypertension. Review of the admission Observation dated 09/05/23 at 3:26 P.M. revealed Resident #118 had no alterations in skin. He was at mild risk for skin impairment. There were no interventions implemented to assist in preventing skin breakdown. Review of the physician's orders for Resident #118 revealed an order dated 09/05/23 to cleanse his left heel wound with normal saline, pat dry, pad and protect with an abdominal (ABD) pad and Kerlix three times a week. This order was discontinued on 09/07/23. Review of Resident #118's baseline…

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 implement a comprehensive and effective infection control program to properly and timely diagnosis, implement necessary infection control precautions, conduct adequate and timely education for staff on infection control relative to preventing the spread of potentially contagious/communicable rashes (scabies) and failed to notify the local health department of potentially contagious skin rashes. This affected three residents (#1, #41, and #81) of three residents reviewed for skin rashes and infection control and had the potential to affect all residents residing at the facility. The facility census was 108. Findings include: On 09/06/23 at 11:53 A.M. and 12:10 P.M. interviews with Licensed Practical Nurse (LPN) #302 and LPN #303 revealed there had been three residents, Resident #1, #41 and #81 with rashes and itching. The Certified Nurse Practitioner (CNP) had followed up and done treatments. There were no other residents and no employees that they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure medications were properly secured in the medication cart on the second floor and failed to ensure medications were discarded when expired. This had the potential to affect the 28 residents (#4, #8 ,#13,#16, #17, #21, #26, #31, #39, #43, #46, #50, #62, #66, #68, #69, #74, #77, #79, #80, #82, #84, #87, #89, #92, #101, #108 and #111) who resided on the second floor. The facility census was 108. Findings include: 1. On [DATE] at 10:08 A.M. observation of the second floor medication cart revealed the cart contained 13 loose medications in the drawers. In addition, there were small holes in the bottom of the drawers which could allow the loose pills to fall through and onto the floor. On [DATE] at 10:20 A.M. interview with Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #317 verified the above finding. The facility identified 28 residents, Resident #4, #8 ,#13,#16, #17, #21, #26, #31, #39, #43, #46, #50, #62, #66, #68, #69, #74,…

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, facility policy and procedure review and interview the facility failed to ensure Resident #5's advance directives/code status was accurately reflected in both the medical record and the electronic medical record. This affected one resident (#5) of 21 residents reviewed for advanced directives. Findings include: A review of Resident #5's hard medical chart revealed the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, panic disorder, major depressive disorder and hypertension. A document titled, Do Not Resuscitate Comfort Care- Arrest (DNR-CCA) was in the hard medical chart. A DNR-CCA means the use of life saving treatments before heart or breathing stops. Review of the physician's order, dated 09/08/20 located in the electronic medical record revealed a code status of full code. A full code status means all emergency life saving measures would be provided in the event of respiratory arrest or cardiac arrest. On 06/13/22 at 8:10…

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, facility policy and procedure review and interview the facility failed to ensure a dressing change/wound care was completed for Resident #14 in a manner to decrease the risk of wound infection. This affected one resident (#14) of one resident observed for wound care. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type II, repeated falls, bacteremia, chronic kidney disease and osteoarthritis. Resident #14 had unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed was obscured by slough or eschar) pressure ulcers to her sacral region and right heel. On 06/14/22 at 3:52 P.M. Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #317 and ADON/RN #314 were observed completing wound care for Resident #14. The staff members entered the resident's room. ADON/LPN #317 placed a barrier and supplies…

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, review of a facility investigation, facility policy and procedure review, manufacturer's guideline review and interview the facility failed to ensure Resident #101 was provided adequate assistance during a staff assisted transfer to prevent the resident from being bumped in the face by the metal support bar of the mechanical (Hoyer) lift. This affected one resident (#101) of two residents reviewed who required a mechanical lift for transfers. Findings include: Review of the medical record for Resident #101 revealed an admission date of 05/13/22 with diagnoses including heart failure, chronic kidney disease, hemiplegia (paralysis of one side of the body), cerebral infarction (stroke) affecting left non-dominant side, muscle weakness and reduced mobility. Review of the plan of care, dated 05/17/22 revealed the resident required two person staff assist for all transfers. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 05/20/22 revealed Resident #101 was cognitively intact and required extensive assistance from two staff for activities of…

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

Based on observation, record review and interview, the facility failed to ensure proper sanitation of dishes and food preparation areas. This had the potential to affect 111 of 113 residents who ate by mouth. Residents #6 and #26 received no food by mouth. Findings include: An initial tour of the kitchen with [NAME] #23 on 06/24/19 from 8:35 A.M. through 9:12 A.M., revealed chicken salad, chili, and prepped grilled cheese were not labeled or dated. The reach-in refrigerator had a container of sliced roast beef and an assortment of cold sandwiches in a pan that were not labeled and dated. The can opener had dried food on the blade, the microwave had food splatter in it, and on the floor beneath the table of the microwave was a build up of dirt, a carton of milk, and paper. Observations during the lunch meal on 06/24/19 at 12:42 P.M. outside the second floor dining room revealed the metal food cart had dried food on the outside especially along the rim. This was verified by Dietary Manager #89 at the time of observation. Interview with Registered Dietitian #26 on 06/27/19 at 7:59 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure resident shower rooms and resident equipment were maintained in a clean and sanitary manner. This affected four out of six shower rooms during two environmental tours and 71 out of 113 residents. Residents #2, #3, #4, #6, #9, #11, #14, #15, #18, 319, #20, #21, #28, #30, #2, #36, #38, #45, #52, #54, #55, #58, #60, #63, #66, #69, #78, #83, #87, #92, #93, #96, #97, #98, #101, #102, #104, #106, #108, #114, #115, #370, and #372 who resided on the third floor were not affected. The facility census was 113. Findings include: 1. Interview with Resident #50 on 06/24/19 at 10:41 A.M. revealed the showers were always dirty. She reported the floors and walls were moldy, there were used razors, razor caps, bottles, and wet wash cloths and towels. Observation on 06/25/19 at 8:15 P.M. with Licensed Practical Nurse (LPN) #55 revealed the shower room on the second floor, C unit, had black colored mold on the ceiling. Observation on 06/25/19 at 8:18 P.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected five (Residents #50, Resident #74, Resident #79, Resident #87 and Resident #110) of seven residents whose assessments were reviewed for accuracy. The facility census was 113. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, unspecified psychosis, major depressive disorder, anxiety, suicidal ideations, and altered mental status. Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. 2. Review of Resident #79's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obsessive, major depressive disorder, bipolar disorder, and schizoaffective disorder. Review of Resident #79's Minimum Data Set (MDS) 3.0…

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 store medications in a secure manner on the 300 unit. This had the potential to affect 32 of 44 residents residing on the secured unit who were cognitively impaired and independently mobile, Residents #3, #4, #9, #11, #14, #15, #18, #20 #21, #28, #32, #36, #38, #45, #52, #58, #60, #66, #78, #79, #83, #87, #92, #96, #98, #101, #102, #104, #106, #108, #115, and #370. The facility also failed to ensure medications on the 100 A/B halls and 300 C cart were labeled as required. This had the potential to affect 33 residents, Residents #6, #7, #10, #13, #27, #33, #37, #39, #41, #46, #47, #49, #53, #64, #65, #72, #74, #91, #94, #95, #100, #103, #105, #4, #15, #36, #58, #69, #76, #87, #98, #109, and #114. The facility census was 113. Findings Include: 1. Observation of the 300 A/B medication cart located on the secured unit on 06/26/19 at 10:15 A.M. revealed the cart was unlocked. Fifteen residents were sitting in the A/B dining room having a snack and other residents were wandering the halls. An activity staff member…

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 infection control standards were followed during a dressing change for Resident #26. This affected one resident observed for dressing change, with a facility census of 113. Findings include: Review of the record of Resident #26 revealed he was admitted to the facility on [DATE] with diagnoses including including traumatic brain injury, quadriplegia, depression, anxiety, peripheral vascular disease, hypertension and chronic pain. Review of his record revealed he was admitted with a pressure area to his coccyx on admission, which was chronic in nature, and also had a non-healing surgical area to his abdomen after a procedure. The pressure area had a dressing in place to include cleansing with normal saline, applying Medihoney alginate (a treatment on a gauze that is applied on the wound) and then covered with a foam dressing. The abdominal wound was to be cleansed with normal saline, then a layer of Gentamycin ointment, and then…

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.