Accord Care Community Orrville LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). Two errors occurred within 30 opportunities for an error rate of 6.67%. This affected one (Residents #13) of four residents reviewed for medication administration. and had the potential to affect an additional 13 residents, (Resident #5, #16, #21, #22, #27, #28, #29, #31, #32, #40, #41, #157, and #158) who received insulin injections. The facility census was 55 residents. Findings include: Record review for Resident #13 revealed an admission date of 09/06/23. Diagnosis included type two diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired. Resident #13 required set up or clean up assistance with meals and partial moderate assistance with personal hygiene. Resident#13 had a diagnosis of diabetes…

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 residents with their preferences during meals. This affected four (#3, #8, #16 and #34) of four residents reviewed for food preferences. The facility census was 55. Findings include: 1. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, adult failure to thrive, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/24, revealed the resident had severely impaired cognition. The resident required partial or moderate assistance for activities of daily living (ADLs). Review of the October 2024 physician orders revealed that Resident #3 was ordered a regular diet with no restrictions and double portions. Review of Resident #3's diet ticket revealed that he disliked orange juice. Observation on 10/22/24 at 7:18 A.M. revealed Resident #3 was sitting up in bed and his breakfast tray 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 medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate. This affected one (Resident #108) of one resident reviewed for advanced directives. The census was 55. Findings include: Medical record review revealed Resident #108 was admitted to the facility on [DATE]. Diagnoses included dementia, insomnia, and hypertension. A Brief Interview for Mental Status (BIMS) dated [DATE] revealed a score of 04/15, which indicated Resident #108 was not cognitively intact. Further review of Resident #108's medical records revealed the hard copy chart included conflicting advanced directives. One advanced directive indicated Full Measures, that required all life saving measures be used. A second advanced directive indicated Do Not Resuscitate - Comfort Care (DNR-CC), that specified Cardio Pulmonary Resuscitation (CPR) was not to be initiated in case of cardiac or respiratory arrest. The DNR-CC was signed by the physician and both forms were 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, record review, and review of the facility policy, the facility failed to timely notify Resident #25's Power of Attorney (POA) of an injury of unknown origin. This affected one (Resident #25) of three residents reviewed for resident representative notification. The facility census was 55. Findings include: Record review for Resident #25 revealed a readmission date of 07/30/19. Diagnoses included age related physical debility, dementia, cognitive communication deficit, Parkinson's disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had impairment on both sides of the upper and lower extremities. Resident #25 was dependent for eating, oral hygiene, toileting, bathing, personal hygiene, bed mobility, chair/bed, bed to chair transfers, and wheelchair mobility. Review of the progress note for Resident #25 dated 09/22/24 timed at 10:53 A.M. completed by Licensed Practical Nurse (LPN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, review of facility reported incidents (FRI) and review of the facility policy, the facility failed to report an injury of unknown origin to the State agency. This affected one (Resident #25) of two residents reviewed for abuse. The facility census was 55. Findings include: Record review for Resident #25 revealed a readmission date of 07/30/19. Diagnoses included age related physical debility, dementia, cognitive communication deficit, Parkinson's disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had impairment on both sides of the upper and lower extremities. Resident #25 was dependent for eating, oral hygiene, toileting, bathing, personal hygiene, bed mobility, chair/bed, bed to chair transfers, and wheelchair mobility. Review of the care plan dated 04/01/24 revealed Resident #25 had potential impairment to skin integrity related to incontinence,…

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, medical record review, review of facility investigations, and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin for Resident #25. This affected one (Resident #25) of two residents reviewed for abuse. The facility census was 55. Findings include: Record review for Resident #25 revealed a readmission date of 07/30/19. Diagnoses included age related physical debility, dementia, cognitive communication deficit, Parkinson's disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had impairment on both sides of the upper and lower extremities. Resident #25 was dependent for eating, oral hygiene, toileting, bathing, personal hygiene, bed mobility, chair/bed, bed to chair transfers, and wheelchair mobility. Review of the care plan dated 04/01/24 revealed Resident #25 had potential impairment to skin integrity related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate treatment was in place for moisture associated dermatitis (MASD) to promote adequate healing. The affected one (Resident #3) of four residents reviewed for skin impairment. Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere and diabetes. Resident #3 resided on the secured memory care unit. Review of Resident #3's care plans revealed an intervention dated 08/15/24 to provide incontinence care and apply barrier cream after each incontinent episode. Review of Resident #3's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory impairment and did not have pressure ulcers. Review of Resident #3's physician orders revealed an order to cleanse the intergluteal cleft and bilateral buttocks with soap and water, apply zinc cream two times a day for MASD…

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 #15 was provided timely incontinence care. This affected one (Resident #15) of two residents reviewed for incontinence care. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, other lack of coordination and schizoaffective disorder. Review of Resident #15's care plans revealed a focus dated 07/09/24 indicating the resident was incontinent of bowel and bladder with interventions including to assess resident for burning, pain and distention, monitor for changes in urinary elimination and provide incontinence care, and apply barrier cream after each incontinent episode. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and was always incontinent of urine and bowel. Review of the undated Nurse 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.

Based on record review, interviews, and facility policy review the facility failed to complete an investigation of an allegation of potential staff-to-resident verbal abuse of Resident #51. This affected one resident (#51) of three residents reviewed for abuse and neglect. The facility census was 58. Findings include: Review of the medical record for the Resident #51 revealed an admission date of 08/07/20. Diagnoses included diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. Review of the comprehensive Minimum Data Set 3.0 (MDS) assessment, dated 07/03/24, revealed Resident #51 had intact cognition and required substantial assistance for activities of daily living (ADL). Further review of the MDS revealed that Resident #51 was incontinent of bowel and bladder. Review of progress notes from 04/01/24 through 08/12/24 revealed no mention of the incident. Review of the care plan revealed that Resident #51 was verbally sexually inappropriate with staff. There was no care plan that stated Resident #51 made false accusations. Interview on 08/13/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor food preferences for Residents #15, #18, and #44. This affected three residents (#15, #18, and #44) out of three residents for food preferences. This had the potential to affect 57 out of 58 residents who received meals from the facility. Resident #24 was identified as receiving nothing by mouth (NPO). The facility census was 58. Findings include: 1. Review of the medical record for the Resident #15 revealed an admission date of 02/05/21. Diagnoses included heart failure, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. The resident required set up for eating and supervision for other activities of daily living (ADL). Review of the physician's orders for August 2024 revealed Resident #15 received a consistent carbohydrate diet (CCD), no added salt (NAS), regular texture with thin consistency liquids. 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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure Payroll Based Journal (PBJ) tracking information submitted by the facility accurately reflected the actual working staff and census. This finding had the potential to affect all 56 residents currently residing in the facility. Findings include: Review of the PBJ Staffing Data Report form submitted from 04/01/23 to 06/30/23 revealed one star staffing rating and excessively low weekend staff. Review of a statement dated 11/02/23 authored by [NAME] President (VP) of Operations #171 indicated the facility was acquired on 01/01/23. The first two quarters of the PBJ data submitted did not have all the working hours reported, nor an organizational process for recording the hours for the PBJ submissions. Interview on 11/02/23 at 10:45 A.M. with VP of Operations #171 indicated the facility did not have all the working hours and inaccurate documentation was submitted on the PBJ reporting website from…

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 review, review of the Centers for Disease Control (CDC) guidance and interview, the facility failed to ensure influenza and pneumococcal vaccines were offered and/or administered as required and the facility failed to ensure residents/responsible parties were educated on the risks and/or benefits of receiving the influenza and pneumococcal vaccines per the facility policy and Centers for Disease Control (CDC) guidelines. This affected five residents (#11, #30, #34, #39 and #49) of six residents reviewed for immunizations. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, other lack of coordination and major depressive disorder. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #11's medical record revealed the resident refused the influenza vaccine 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 closed record review and interview, the facility failed to ensure a final accounting of Resident #408's resident fund account within 30 days after the resident's discharge from the facility. This affected one resident (#408) of five residents reviewed for resident fund accounts. Findings include: Review of Resident #408's closed medical record revealed the resident was admitted on [DATE] and discharged to another facility on 09/08/23 with diagnoses including acute respiratory failure with hypoxia, malignant neoplasm of the skin and weakness. Review of Resident #408's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #408's resident fund account and ending balance statement dated 11/01/23 revealed the resident had $472.00 in his resident fund account. Interview on 11/02/23 at 7:05 A.M. with Business Office Manager (BOM) #164 confirmed the monies in Resident #408's resident fund account were not dispersed within 30 days as required.

Based on observation, record review, facility policy review and interview, the facility failed to ensure a safe, homelike environment for Resident #36. This affected one resident (#36) of resident one resident for room temperature. Findings include: Review of the medical record for Resident #36 revealed an admission date of 08/09/23 with diagnoses including but not limited to adult failure to thrive, alcohol abuse and hypokalemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/30/23, revealed Resident #36 had no cognitive impairment. On 10/31/23 at 9:39 A.M. interview with Resident #36 revealed she was cold. Observation and interview on 10/31/23 at 9:58 A.M. with State Tested Nursing Assistant (STNA) #140 verified the resident's room felt cold; the STNA then looked at the thermostat behind the bed that against the wall. STNA #140 stated that the thermostat was set for 65 degrees Fahrenheit (F). Resident #36 stated that she could not reach it and STNA #140 turned it up. Observation and interview on 10/31/23 at 9:58 A.M. with Maintenance Director (MD) #170…

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 interview, the facility failed to ensure resident admission comprehensive assessments were accurate. This affected one resident (#11) of 22 residents reviewed for comprehensive assessments. The facility census was 56. Findings include: Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including schizophrenia, major depressive disorder and anxiety disorder. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was not currently considered by the State Level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. Further review of the admission MDS assessment dated [DATE] revealed schizophrenia was not coded as an active diagnosis. On 11/01/23 at 10:14 A.M. and 10:26 A.M., interview with Clinical Resource Specialist #201 verified Resident #11 had a diagnosis of schizophrenia, depression and anxiety disorder…

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 complete and accurate. This affected three residents (#11, #30 and #39) of 22 residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, depressive disorder and mood disorder. Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and during the look back period of 08/03/23 to 08/09/23, the resident received seven days of a hypnotic, anticoagulant, antibiotic, diuretic and opioid. Review of Resident #30's medication administration records (MARS) from 08/03/23 to 08/09/23 revealed the resident did not receive any doses of a hypnotic medication, an anticoagulant medication, an antibiotic medication, a diuretic medication or an opioid medication. Interview on 11/01/23 at 8:55 A.M. with Licensed Practical Nurse…

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 timely complete the Pre-admission Screening and Resident Review (PASRR) for Resident #11 and #24. This affected two residents (#11 and #24) of two residents reviewed for PASRR. The census was 56. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 09/16/22 with diagnoses including dementia with behavioral disturbance, recurrent depressive disorders, brief psychotic disorder, and cognitive communication deficit. Further review of the diagnoses revealed a new diagnosis of delusional disorder was added on 03/07/23. Review of the Pre-admission Screening and Resident Review (PASRR), completed 09/14/22, revealed Resident #24 had a diagnosis of mood disorder. No other diagnoses were identified on the PASRR and the results indicated she had no indication of serious mental illness. There was no PASRR completed at the time of the new diagnosis of delusional disorder, added 03/07/23. On 11/01/23 at 9:57 A.M., interview…

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 develop comprehensive care plans for all residents to meet their total care and assessed needs. This affected one resident (#39) of five residents reviewed for unnecessary medications and one resident (#11) of one resident reviewed for accidents. The facility census was 56. Findings include: 1. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder, cerebral infarction without residual deficits, weakness, and abnormalities of Gait and mobility. Review of the Restraint Enabler Decision Tree assessment dated [DATE] revealed 1/2 bed side rails did not prevent the resident from performing an action that they are otherwise capable of performing. Review of the Potential for ADL Self Care Performance deficit revised 10/30/23 revealed bilateral 1/2 side rails to assist with bed mobility. Further review of the record revealed no evidence the bed rails were comprehensively…

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 timely revise resident care plans. This affected one resident (#39) of 22 residents reviewed for assessment and care planning. The census was 56. Findings include: Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including but not limited to bipolar disorder, dementia, dysphagia, cognitive communication deficit and protein calorie malnutrition. The resident was unable to answer screening questions appropriately at the time of the survey. Review of the Base-Line admission Care Plan dated 07/24/23 revealed Resident #39 had natural teeth. Staff was to observe the oral cavity, report abnormal findings, evaluate need for dental services, provide oral care, monitor and report dental pain as indicated. Review of the Emergency Dental Form 09/07/23 revealed Resident #39 was having some issues with her teeth hurting and family wanted her to be evaluated. The resident had several broken teeth and was having…

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 #3's percutaneous endoscopic gastrostomy (PEG) tube dressing was changed per the physician's orders. This affected one resident (#3) of two residents reviewed for PEG tubes. Findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, spastic hemiplegia affecting the left non-dominant side and encounter for attention to gastrostomy. Review of Resident #3's physician orders revealed an order revised 05/15/22 to cleanse the PEG tube site with soap and water and cover with a dry sterile dressing every night shift. Review of Resident #3's medication administration records (MAR) and treatment administration records (TAR) from 10/01/23 to 10/31/23 revealed documentation on the TAR revealed the resident's PEG tube dressing was changed as ordered on 10/29/23, 10/30/23 and 10/31/23. Observation on 10/31/23 at 5:03 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 observation, record review and interview, the facility failed to ensure Resident #3's left thumb pressure ulcer wound care was completed per the physician's order. This affected one resident (#3) of one resident reviewed for pressure ulcers. Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, aphasia and spastic hemiplegia affecting the right dominant side. Review of Resident #3's nursing progress note dated 10/30/23 at 3:59 A.M. indicated the resident's left thumb was slightly edematous with serous and bloody discharge noted. The measurements were unable to be obtained and the resident's thumb was cleansed with warm water and soap, the wound was dried, a nonstick Telfa dressing was applied and the thumb was wrapped with Kerlix. The wound nurse, physician and Director of Nursing (DON) was notified. Review of Resident #3's physician orders revealed an order dated 10/30/23 to cleanse the left thumb with normal…

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, medical record review and interview, the facility failed to ensure respiratory supplies were changed weekly as ordered and nebulizer masks stored appropriately for Resident #5. This affected one resident (#5) of one resident reviewed for respiratory services. The facility census was 56. Findings include: Review of Resident #5's medical record revealed an admission date of 08/07/20 with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus and congestive heart failure. Further review of the medical record including physician's orders revealed orders for supplemental oxygen use to maintain oxygen saturation levels above 92%, change oxygen tubing weekly on Saturday and change nebulizer kit/tubing weekly on Saturday. Review of the Medication Administration Record (MAR) for the month of October 2023 revealed oxygen tubing and nebulizer tubing documented as changed on 10/07/23, 10/14/23, 10/21/23 and 10/28/23. Observation of Resident #5 on 10/31/23 at 9:40 A.M. revealed the resident lying in bed with supplemental oxygen in place by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to provide appropriate alternatives prior to the use of bed rails for Resident #11. This affected one resident (#11) of one resident reviewed for bed rails. The facility census was 56. Findings include: Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including unspecified dementia, lack of coordination, major depressive disorder, anxiety disorder and cerebral infarction without residual deficits, weakness, and abnormalities of gait and mobility. Resident #11 resided on the secured memory care unit and was unable to be interviewed due to cognitive impairment and an inability to answer questions appropriately. Review of the Restraint Enabler Decision Tree assessment dated [DATE] revealed Resident #11 used a left enabler bar to move in and out of bed. The assessment indicated the enabler bar improved the resident's function. Review of the Restraint Enabler Decision Tree 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 observation, medical record review, policy review and interview, the facility failed to ensure timely and accurate dental evaluations were completed. This affected one resident #39) of one resident reviewed for dental services. The facility census was 56. Findings include: Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including but not limited to bipolar disorder, dementia, dysphagia, cognitive communication deficit and protein calorie malnutrition. The resident was unable to answer screening questions appropriately at the time of the survey. Review of the Base-Line admission Care Plan dated 07/24/23 revealed Resident #39 had natural teeth. Staff was to observe the oral cavity, report abnormal findings, evaluate need for dental services, provide oral care, monitor and report dental pain as indicated. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #39 was severely impaired for daily decision-making, had no dental concerns and was…

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

Based on observation, consumption of pureed foods, record review and policy review, the facility failed to ensure pureed foods were prepared to a proper consistency and failed to substitute an appropriate food item for pureed rice during the meal on 11/01/23 to ensure the meal was palatable, appetizing and ensured safe swallowing. This affected two residents (#12 and #39) of two residents identified by the facility to have orders for pureed diets. Findings include: Observation of pureed food preparation on 11/01/23 at 10:31 A.M. revealed Dietary Manager (DM) #165 was observed to puree rice for the lunch meal. Following the preparation, the pureed rice was tasted and noted to have small pieces of rice in it. DM #165 verified the rice was not pureed enough and proceeded to puree the rice for several more minutes. DM #165 could not get the rice to puree smoothly, so she then changed the puree starch to mashed potatoes for the meal (as opposed to substituting the mashed potatoes for the rice to begin with). Continued observation on 11/01/23 revealed DM #165 was observed to pureed…

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 resident food preferences were honored. This affected one resident (#32) of one resident reviewed for food preferences. Findings include: Review of the medical record for Resident #32 revealed an admission date of 10/16/23 with diagnoses including ulcerative colitis, alcohol abuse, and cirrhosis of liver. Review of Resident #32's preference sheet dated 10/16/23 revealed Resident #32 stated her preference was to be gluten free. Review of the Resident Preference Interview dated 10/16/23 for Resident #32 revealed Resident #32 does not eat gluten for personal comfort. Review of the physician's orders for November 2023 identified orders for a no added salt, low fat and low cholesterol diet with regular texture and regular liquid consistency. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/23/23 revealed Resident #32 had no cognitive impairment. Interview on 10/31/23 at 9:31 A.M. with Resident # 32 revealed that she is on a gluten free diet. Resident #32 stated that the facility…

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

Based on record review and interview the facility failed to ensure resident medical records were accurate and completed to reflect incidents and the residents current status. This affected two residents (#24 and #51) of two residents reviewed for abuse and one resident (#24) of 22 residents reviewed for assessments and care planning. The census was 56. Findings include: 1. Review of a facility Self-Reported Incident (SRI), tracking number 240551, dated 10/25/23, revealed there was an incident between Residents #24 and #51 that occurred on 10/24/23. Review of the medical record for Resident #24 revealed an admission date of 09/16/22 with diagnoses including dementia with behavioral disturbance, recurrent depressive disorders, brief psychotic disorder, and cognitive communication deficit. Review of the progress notes for October 2023 for Resident #24 revealed there were no progress notes regarding the incident that occurred on 10/24/23 between Residents #24 and #51. Review of the medical record for Resident #51 revealed an admission date of 10/24/22 with diagnoses including…

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 facility failed to ensure Resident #23's advance directives located in the medial records reflected what was in the electronic health records. This finding affected one (Resident #23) of 24 residents reviewed for advanced directives. Findings include: Review of medical record for Resident #23 revealed an admission date of 10/01/18 and diagnoses of diverticulitis of both small and large intestine, chronic obstructive pulmonary disease with acute exacerbation and chronic obstructive pulmonary disease. Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the physician orders in the electronic health record revealed an order for Full Code (all resuscitation procedures to be provided) status per family request effective 05/26/21. Review of Ohio Do Not Resuscitate (DNR) Identification form dated 10/09/18 located in the resident's paper medical record revealed the resident's code status was…

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

Based on record review, review of liability notices and staff interview, the facility failed to ensure residents received the appropriate liability notices and timely notification when their skilled services ended. This affected three (Residents #15, #23 and #50) of three residents reviewed for liability notices. Facility census was 52. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 05/24/21 with diagnoses including multiple myeloma (cancer), hypertension, muscle weakness and lack of coordination. Resident #15 remained in the facility after discontinuation of Medicare A services. However, the facility did not provide the resident with the Advanced Beneficiary Notice (ABN) which would have informed him of the daily rate to remain in the facility along with other options. Interview on 08/24/21 at 4:57 P.M. with Admissions #573 verified Resident #15 did not receive the ABN prior to services ending. 2. Review of the medical record for Resident #23 revealed an admission date of 10/01/18 with diagnoses including diabetes mellitus, chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to provide privacy during family visits. This affected two (Resident #28 and Resident #32) of five residents observed for visitation. The census was 52. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder, and agoraphobia with panic disorder. The resident's brother was listed as his next of kin and durable power of attorney. Review of the annual comprehensive minimum data set assessment (MDS) dated [DATE] indicated Resident #28 was moderately impaired in daily decision-making ability and it was somewhat important to the resident to be able to use the telephone in private. Interview and observation on 08/24/21 at 2:12 P.M. revealed Resident #28 in the front lobby visiting with his brother, both were seated at a table six feet apart. Resident #28's brother stated that the visits were difficult due to the front lobby…

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, record review and interview, the facility failed to maintain a clean and sanitary environment and ensure bed linens were clean. This affected three (Residents #28, #29 and #38) of 52 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 04/23/19. Diagnoses included unspecified dementia, anxiety disorder, excoriation (skin-picking) disorder, atopic dermatitis, and pruritis. Observations on 08/23/21 at 12:05 P.M. revealed Resident #38 was dressed, lying her head on the pillowcase which had spots of dry blood. The resident also had two bandages on her left forearm. The resident verified the blood on the pillowcase and stated the pillowcase was changed a couple of days ago. Observations on 08/23/21 at 1:41 P.M. revealed Resident #38 was lying her head on the same pillowcase. On 08/23/21 at 1:57 P.M. Licensed Practical Nurse (LPN) #500 verified the blood on the pillowcase and stated he would change the pillowcase immediately. 2. Medical record review for Resident #29 revealed 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.