Greenbrier Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy revealed the facility failed to ensure infection control practices were maintained while assessing Resident #40, #87, #104 and #138 using a shared glucometer and failed to adhere to Enhanced Barrier Precautions (EBP) while providing catheter care to Residents #35 and #38. This affected six residents (Resident #40, #87, #104, #138, #35 and #38) of eight residents reviewed for infection control. The facility census was 123. Findings include:1. Record review for Resident #104 revealed an admission date of 08/06/24. Diagnosis included diabetes mellitus (DM) with diabetic peripheral angiopathy without gangrene.Review of the Significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 was moderately cognitively impaired. Review of the Care Plan dated 05/09/23 revealed Resident #104 had DM with interventions to obtain blood sugars per order. Review of the physician order for Resident #104 dated 06/19/24…

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 advance directives were updated in the medical record to reflect resident's current wishes. This affected one resident (Resident #10) of 60 residents reviewed for advanced directives. The facility census was 123. Findings include: Review of the medical record for Resident #10 revealed an admission date of [DATE]. Diagnoses included but were not limited to Ogilvie syndrome, atrial fibrillation, type II diabetes mellitus, morbid obesity and schizophrenia.Review of the [DATE] discharge Minimum Data Set (MDS) 3.0 for Resident #10 revealed intact cognition.Review of the [DATE] uploaded code status form under the miscellaneous tab of the electronic medical record revealed a [DATE] signed document for Resident #10 for an advance directive of Do Not Resuscitate Comfort Care Arrest.Review of the electronic medical record (EMR) revealed under the blue banner bar revealed a code status to provide cardiopulmonary resuscitation (CPR).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 record review, interview and review of the facility policy, the facility failed to ensure the resident/responsible party received the Notice of Medicare Non-Coverage (NOMNC) timely and as required. This affected one resident (#123) of three residents reviewed for liability notices. The facility census was 123. Findings include:Record review for Resident #123 revealed an admission date of 05/12/25. Diagnosis included cerebral palsy, morbid severe obesity, muscle weakness, and need for assistants with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #123 revealed Resident #123 was cognitively intact. Resident #123 had no impairment to the upper or lower extremities, required supervision or touch assistants with eating, dependent for toileting, personal hygiene, substantial/max assist bed mobility and dependent for chair/bed to chair transfers. Review of the physician orders for Resident #123 dated 06/11/25 revealed PT eval completed this date. Recommend PT services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to develop individualized plans of care. This affected three residents (#67, #71 and #117) out of 44 resident records reviewed. Facility census was 123.Findings include: 1.Review of Resident #67's medical record revealed an admission date of 06/17/23 and diagnoses including chronic respiratory failure with hypoxia, epilepsy, hypertension, bipolar disorder, quadriplegia and contractures to bilateral hands, knees and hips. Review of Resident #67's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 had a memory problem with severe cognitive impairment. Resident #67 had highly impaired vision, adequate hearing and was dependent on staff for activities of daily living (ADLs). Review of the sexual offender log for August and September 2025 revealed a referral date of 03/17/25 for Resident #67. The national and state sex offender registries indicated Resident #67 was a sex offender with a readmission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise a resident's care plan to reflect a residents current needs. This affected two of (Resident #69 and #117) of forty four sampled Residents. The facility census was 123.Findings include: 1. Resident #117 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Steele-[NAME]-[NAME] syndrome (an extremely rare brain disease that gradually impairs balance, eye movement, speech, and swallowing), and dementia. Review of Resident #117's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #117 was moderately cognitively impaired, utilized a walker for ambulation, and required setup assistance for completing activities of daily living. The assessment also documented that Resident #117 engaged in wandering behaviors every one to three days and identified his primary language as Russian. Review of Resident #117's care plan problem dated 07/19/25 revealed Resident #117 was considered an elopement risk 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 Resident #38's pressure ulcer wound care dressings were completed as ordered. This finding affected one (Resident #38) of seven residents reviewed for pressure wounds. Findings include:Findings include:Review of Resident 38's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including quadriplegia, diabetes and schizophrenia.Review of Resident #38's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #38's physician orders revealed an order dated 09/17/25 to cleanse the mid-spine, right back, sacrum, right ischium, left buttock, right lateral leg and left lower extremity with wound cleanser, apply collagen sheet to the base of the wound and secure with a bordered foam dressing daily and as needed.Review of Resident #38's wound progress note dated 09/24/25 at 3:39 P.M. revealed the resident had a mid-spine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide Resident #119 with timely incontinence care. This finding affected one (Resident #119) of eleven residents reviewed for incontinence care. Findings include:Review of Resident #119's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease and diabetes.Review of Resident #119's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was frequently incontinent of bowel and bladder and required substantial/maximal assistance with toileting hygiene.Review of Resident #119's Activities of Daily Living (ADL) Self-Performance Care Plan revealed an intervention dated 05/09/25 which indicated the resident required substantial/maximal assistance with toileting hygiene.Observation on 09/22/25 at 9:45 A.M. of Certified Nursing…

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, staff interview and facility policy review, the facility failed to ensure one Resident #67's enteral feeding was labeled and dated as required. This affected one resident (Resident #67) of four residents requiring enteral feedings at the facility. Findings include:Review of the medical record for Resident #67 revealed an admission date of 09/09/25. Diagnoses included but were not limited to chronic respiratory failure with hypoxia, use of gastrostomy, traumatic subdural hemorrhage, epilepsy, contracture of right and left hand, right knee, left knee, right hip, bipolar disorder, tracheostomy, and quadriplegia.Review of the 09/06/25 discharge Minimum Data Set (MDS) 3.0 for Resident #67 revealed severe cognitive impairment and dependence upon staff for all activities of daily living.Review of the physician order dated 09/10/25 for Resident #67 revealed he received nothing by mouth.Review of the 06/03/25 physician order for Resident #67 revealed an order for enteral nutrition via pump of Jevity 1.5 calorie formula at 50 milliliters (mL) per hour for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain tracheostomy care and ensure clean suctioning equipment and trach replacement supplies were available for Resident #14. This affected one resident (Resident #14) of one resident reviewed for trach care. Findings include: Record review for Resident #14 revealed an admission date of 11/09/23. Diagnosis included cranial cerebrospinal fluid leak, tracheostomy, dysphagia, other symptoms and signs involving cognitive functions and awareness, cognitive communication deficit, muscle weakness, and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was severely cognitively impaired. Resident #14 had impairment on one side of the upper extremities and required assistants with activities of daily living (ADL). Resident #14 did not receive oxygen therapy, received suctioning, and trach care. Review of the Care Plan revised 08/08/24 revealed Resident #14 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 interview, record review, and facility policy review the facility failed to ensure Resident #8 was monitored prior to and following dialysis treatments. This affected one (Resident #8) of one resident reviewed for dialysis. Findings include:Review of the medical record for Resident #8 revealed an admission date of 07/20/24. Diagnoses included but were not limited to type II diabetes mellitus with chronic kidney disease, moderate protein-calorie malnutrition, stage five chronic kidney disease, and dependence on renal dialysis.Review of the 08/10/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #8 revealed intact cognition, required supervision for dressing and personal hygiene and was noted to receive dialysis.Review of the physician order dated 07/30/24 for Resident #8 revealed an order to send medication list, face sheet and dialysis assessment with resident on Monday, Wednesday and Friday. Night shift to prepare paperwork every night shift on Tuesday, Thursday and Sunday. Review of the physician order dated 03/31/25 for Resident #8 revealed an order for Dialysis every…

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 of medication administration, interview, record review, and review of the instructions for insulin pen-injections, the facility failed to ensure medications were administered as ordered resulting in a medication errors rate of 6.7 percent (%). This affected two residents (Resident #87 and #138) out of five residents observed for medication administration. The facility census was 123.Findings include:1. Record review for Resident #138 revealed an admission date of 05/20/25. Diagnosis included diabetes mellitus with diabetic chronic kidney disease.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #138 was cognitively intact. Resident #138 received insulin injections daily. Review of the Care Plan dated 06/02/25 revealed Resident #138 had diabetes with diabetic neurological complications. Interventions included to administer insulin injections per medical providers orders.Review of the physician orders for Resident #138 dated 08/28/25 revealed orders for Insulin…

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 ensure Resident #133 and Resident #136 was free from significant medications error. This affected two residents (Resident #133 and #136) of three residents reviewed for medication errors. The facility census was 123.Findings include: 1.Record review for Resident #133 revealed an admission date of 01/14/25 and a discharge date of 03/26/25. Diagnosis included Crohn's disease, muscle weakness, abdominal pain, and other chronic pain. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #133 was moderately cognitively impaired. Resident #133 received scheduled and as needed pain medications. Pain frequency was almost constantly and frequently had an effect on sleep. Review of the care plan dated 02/02/25 revealed Resident #133 has complaints of acute/chronic pain or at risk for pain related to Crohn's disease, intervertebral disc degeneration, lumbosacral region, abdominal pain, vitreous degeneration,…

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, interview, and policy review the facility failed to administer pain relieving medications as ordered. This affected one (Resident #8) of three residents reviewed who received pain medications. The census was 120. Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/14/25. Diagnoses included Crohn's disease of large intestine with fistula, intervertebral disc degeneration, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/21/25, revealed Resident #8 had intact cognition and chronic pain. Review of the plan of care dated 02/02/25 revealed Resident #8 had complaint of acute/chronic pain related to Crohn's disease, intervertebral disc degeneration, lumbosacral region, abdominal pain, and other chronic pain. Interventions included attempting non-pharmacological interventions, complete pain assessments, follow physician orders, and observe for pain every shift. Interview on 03/07/25 at 10:38 A.M. with the Administrator revealed on 02/25/25 Assistant Director of Nursing (ADON)…

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, interviews and policy review the facility failed to ensure effective discharge planning was in place for two residents (Residents #125 and #126) of three residents reviewed for discharge planning. The facility census was 123. Findings include: 1. Review of the closed medical record for Resident #125 revealed an admission date of 04/30/24 and a discharge date of 12/04/24. Diagnoses included but were not limited to diabetes mellitus with neuropathy, spondylosis, psychoactive substance abuse, and vascular dementia. Review of Resident #125's care plan revealed it was last reviewed on 04/2024 and stated the resident had no plans for discharge to the community. Review of Resident #125's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #125 used a walker and required supervision for ADLs. 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 of observation, interview, record review,Self-Reported Incident (SRI) , and facility policy review, the facility failed to ensure all staff followed Mechanical lift protocol. This affected one (Resident #135) of three residents reviewed for safe transfer with Mechanical lift. This had the potential to affect 33 residents that required the use of a mechanical lift for transfers (Resident #1, #3, #9, #10, #18, #27, #37, #38, #39, #44, #48, #49, #51, #54, #56, #57, #64, #68, #70, #71, #78, #81, #85, #88, #89, #94, #110, #114, #115, #122, #123 and #135). The facility census was 122. Findings include: Review of the closed medical record for Resident #135 revealed an admission date of 02/01/24 and discharged on 08/22/24. Diagnoses included diabetes, chronic kidney disease, morbid obesity, spinal stenosis and osteoarthritis. Resident #135 had intact cognition. Resident #135 was dependent on transfers and used a mechanical lift (Hoyer) for transfers. 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 provide timely incontinence care. This affected four (#102, #115, #117, and #120) of six residents observed for incontinence care. The facility census was 128. Findings include: 1. Review of Resident #102's medical records revealed an admission date of 12/05/23. Diagnoses included Alzheimer's disease, dementia, muscle weakness and need for personal care assistance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 had impaired cognition, was dependent with toileting, and was incontinent of bowel and bladder. Review of Resident #102's care plan dated 06/10/24 revealed Resident #102 was totally dependent for toileting. Resident #102 was incontinent of bowel and bladder and interventions included to check Resident #102 for incontinence. Interviews on 07/31/24 at 5:15 A.M. with State Tested Nursing Assistant (STNA) #213 and STNA #239 revealed they were aware of residents who did not receive timely 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 record review, interview and review of a local police report, the facility failed to ensure resident requests were honored and residents were treated with respect and dignity at all times. This affected one (#120) of 10 sampled residents and two residents who participated in random interviews (#108 and #8). The facility census was 128. Findings include: 1. Review of Resident #120's medical records revealed an admission date of 02/01/24. Diagnoses included morbid obesity, need for personal care assistance, muscle weakness and difficulty walking. Review of Resident #120's care plan dated 02/01/24 revealed Resident #120 required assistance with activities of daily living (ADL) by one staff who performed all the care and was totally dependent for transfers. Resident #120 preferred to get up into her wheelchair between breakfast and lunch and preferred to lay down before dinner daily. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 had intact cognition and was dependent…

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

Based on observation and interview the facility failed to ensure a clean and sanitary environment. This affected two (#67 and #117) of five random residents whose rooms were observed. The facility census was 128. Findings include: Observation on 07/31/24 at 8:05 A.M. with State Tested Nursing Assistant (STNA) #230 and STNA #293 revealed two soiled incontinence briefs on Resident #117's wheelchair with gnats flying around them. Interview with STNA #230 at time of observation revealed when she entered Resident #117's room the incontinence briefs were on the floor and she had picked them up and placed them on Resident #117's wheelchair. Observation on 07/31/24 at 9:09 A.M. revealed a large pile of dirty linens on the floor of Resident #67's room with a foul odor detected. Interview with Resident #67 at time of observation revealed the dirty linens had been on the floor since last night when they changed his bed. The observation was confirmed by STNA #330 who indicated she would dispose of the linens. This deficiency represents non-compliance investigated under Complaint Number…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #135 received appropriate discharge instructions. This finding affected one resident (#135) of three residents reviewed for discharge instructions. Findings include: Review of the medical record revealed Resident #135 was admitted on [DATE] and discharged on 03/29/24 with diagnoses including diabetes, essential hypertension, and muscle weakness. Review of Resident #135's Report and Decision of the Hearing Officer form dated 02/22/24 revealed the resident won the appeal, and the facility may not discharge and transfer the resident based on non-payment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #135 exhibited intact cognition. Review of the Notice of Discharge and Transfer form dated 02/28/24 revealed Resident #135 was being discharged for an unpaid balance of $11,520.00. The resident did not appeal the second notice. Review of the progress note dated 03/19/24 at 10:22 A.M. indicated…

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, interviews, and menu review, the facility failed to serve hot, palatable, and visibly pleasing foods. This affected Residents #17, #19, #20, #28, #34, #108, and had the potential to affect all residents, except Residents #23, #25, #63, #100, and #115 who were identified as not consuming food by mouth (NPO). The facility census was 131. Findings include: Interview with Resident #28 on 02/14/24 at 6:18 A.M. revealed the facility's food had no flavor and he wouldn't feed it to a dog. Interview with Resident #19 on 02/15/24 at 7:40 A.M. revealed the facility's food was terrible. Interview with Resident #17 on 02/15/24 at 7:57 A.M. revealed the facility's food was cold and not hot enough. Observation on 02/15/24 at 10:00 A.M. with State Tested Nursing Assistant (STNA) #948 revealed she was using the first floor unit microwave behind the nursing station adjacent to Resident #17's room. Interview with STNA #948, at the time of the observation, revealed Resident #20's food was cold and Resident #20 requested that it to be warmed up. Review of the facility menu for 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 and staff interview, the facility failed to ensure staff wore hair coverning when in the kitchen. This had the potential to affect all residents, except Residents #23, #25, #63, #100, and #115 who were identified as not consuming food by mouth (NPO). The facility census was 131. Findings include: Observation and interview on 02/15/24 at 1:00 P.M. revealed Kitchen Aide (KA) #814 entering the kitchen from the door located near the first floor dining room and walking from one side of the kitchen to the opposite side entrance, near the front entrance of the facility, without a hairnet in place. Interview with KA #814 revealed she went to get something to drink and did not want to walk all the way around to reenter the kitchen. Interview on 02/21/24 at 9:40 A.M. with Corporate Dietary Manager (CDM) #959 revealed there were no hairnets for kitchen staff use located at the entry to the kitchen from the first floor dining room. Review of the facility provided list revealed Residents #23, #25, #63, #100, and #115 were identified as not consuming food by mouth (NPO).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of personnel file, the facility failed to ensure staff who clocked in for work with symptoms of Covid-19 were immediately tested and or sent home. This had the potential to affect all residents. The facility also failed to ensure urinary catheter drainage bags were not placed on the floor. This affected one (#85) of two residents reviewed for urinary catheters. The facility census was 131. Findings include: 1. Review of Resident #85's medical records revealed an admission date of 12/15/23. Diagnoses included stroke with left sided weakness, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had impaired cognition, had an indwelling urinary catheter and was incontinent of bowel. Review of the care plan dated 12/22/23 revealed Resident #85 had an indwelling urinary catheter related to obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). 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 resident record review, resident interviews, staff interviews, staff personnel files, and facility policy, the facility failed to ensure residents were treated with respect and dignity. This affected six residents who were interviewed, whose records were reviewed, or were observed during random observations (#9, #11, #71, #109, #112, and #115) and had the potential to affect all residents residing in the facility. The facility census was 131. Findings include: 1. Interview on 02/14/24 at 5:37 A.M. with Resident #115 revealed sometimes the nurses were rude to him while giving him medications. Interview on 02/14/24 at 7:28 A.M. with Resident #71 revealed he was able to provide most of his own care but there were staff who had been rude. Interview on 02/15/24 at 10:45 A.M. with Resident #112 revealed sometimes state tested nurse aides were rude to him and did not treat him with respect and dignity. 2. Review of the medical record for Resident #11 revealed an admission date of 11/20/23 with diagnoses 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 observation, resident interviews, staff interviews, and facility policy review, the facility failed to maintain a clean and sanitary environment. This affected seven (#17, #89, #90, #110, #111, #112, #113, and #115) residents and had the potential to affect all residents. The facility census was 131. Findings include: Observation on 02/14/24 at 5:24 A.M. revealed a food cart with multiple dirty dinner dishes located on the second floor. Interview on 02/14/24 at 5:31 A.M. with State Tested Nurse Assistant (STNA) #941 confirmed the dirty dishes in the hall and stated she was not aware of who was supposed to take them down to the kitchen. STNA #941 believed the dishes should have been taken down to the kitchen on the previous shift because dinner was done by the time she arrived for her shift. Observation of Resident #115's room on 02/14/24 at 5:37 A.M. revealed the wall underneath the air conditioning (AC) unit had a large amount of chipped paint. Interview with STNA #941 at the time of the observation confirmed the chipped paint. Observation of Resident #17's room on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure ongoing monitoring and timely intervention for residents with symptoms of urinary tract infections and failed to provide timely and appropriate incontinence care and toileting assistance. This affected one (#115) of two residents reviewed for urinary catheters, and four (#15, #17, #117 and #136) of four residents reviewed for incontinence. The facility census was 131. Findings include: 1. Review of Resident #115's medical records revealed an admission date of 09/16/22. Diagnoses included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 had intact cognition, had a urinary catheter and was incontinent of bowel. Review of the care plan dated 01/16/24 revealed Resident #115 had a urinary catheter. Interventions included report signs and symptoms that included foul smelling urine to the physician. 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 resident record review, observations, and staff interviews, the facility failed to ensure assistive devices were in place for meals. This affected three (#97, #125 and #126) of three residents reviewed for assistive devices during meals. The facility census was 131. Findings include: Observation of the lunch meal tray line on 02/15/24 at 1:17 P.M. with Kitchen [NAME] (KC) #957 revealed the meal tickets of three residents (#97, #125, and #126) were set to the side. The meal tickets indicated the assistive devices each resident required with meals. Continued observation revealed KC #957 looking throughout the kitchen for the required assistive devices. Interview with KC #957, at the time of the observation, revealed Residents #97 and #126 required a scoop plate and Resident #125 required a divided plate and they had already used the assistive plates that were available, there were no more assistive plates. Observation and interview on 02/15/24 at 1:23 P.M. with the Administrator, who was assisting 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 resident record review, observation and staff interview, the facility failed to ensure reasonable requests made by a resident's guardian were honored. This affected one (#1) of one resident reviewed for reasonable requests made by a guardian. The facility census was 131. Findings include: Review of the medical record for Resident #1 revealed an admission date of 11/27/23 with diagnoses that included quadriplegia, acute and chronic respiratory failure with hypoxia, tracheostomy status, traumatic subdural hemorrhage with loss of consciousness of unspecified duration and contractures of the left and right hip and left and right knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was severely impaired for task of daily life and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/31/24 revealed Resident #1 required assistance with ADLs related to quadriplegia and a traumatic brain injury. Review of the progress note…

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, record review, and personnel file review, the facility failed to ensure medications were administered according to accepted standards of practice. This affected one resident (#10) identified during a random observation. The facility also failed to ensure pain medications were administered as ordered by the physician and requested by the resident. This affected two of 14 sampled residents (#21 and #22). The facility census was 131. Findings include: 1. Observation on 02/14/24 at 9:09 A.M. revealed Unit Manger/Licensed Practical Nurse (LPN) #848 at a medication cart preparing medications for administration. LPN #848 was observed popping pills out of medication cards into a medication cup. LPN #848 handed the medication cup to Registered Nurse (RN) #828, who took the medications into Resident #10's room. Interview with LPN #848 at time observation revealed she was helping RN #828 with her medication pass. Interview on 02/14/24 at 10:31 A.M. with RN #828 revealed she administered the medications given to her by LPN #848 to Resident #10. RN #828 explained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and policy review, the facility failed to appropriately care for a Percutaneous Endoscopic Gastrostomy (PEG) tube site to identify, lessen or resolve possible skin irritation and local infection. This affected one (#115) of two residents reviewed for PEG tubes. The facility census was 131. Findings include: Review of Resident #115's medical records revealed an admission date of 09/16/22. Diagnoses included gastrostomy (artificial opening in the abdomen for nutrition). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 had intact cognition and required extensive assistance with activities of daily living (ADL). Review of the care plan dated 01/1/6/24 revealed Resident #1 had a PEG tube. Interventions included provide insertion site care per orders. Observation of Resident #115 on 02/14/24 at 5:37 A.M. with State Tested Nursing Assistant (STNA) #941 revealed Resident #115 had a PEG tube. Observation of the PEG tube insertion site…

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 appropriate respiratory care equipment was at the resident's bedside for immediate access. This affected two (#1 and #17) of two residents reviewed for tracheostomy care. The facility census was 131. Findings include: 1. Review of Resident #17's medical records revealed an admission date of 11/09/23. Diagnoses include tracheostomy and dysphasia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition. Review of the care plan dated 01/31/24 revealed Resident #17 had a tracheostomy. Interventions included keep an extra trach at the bedside and provide suctioning per orders. Review of current physician orders for February 2024 revealed to suction resident every shift and as needed. Observation on 02/14/24 at 8:38 A.M. revealed Resident #17 was exhibiting signs of inability to clear his airway. At the time of observation Licensed Practical Nurse (LPN) #866 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, interview and policy review, the facility failed to ensure medications were not left unattended in resident rooms. This affected one (#72) of three residents whose rooms were randomly observed for unsecured medications. The facility census was 131. Findings include: Observation on 02/14/24 at 7:28 A.M. revealed Resident #72 was sleeping in bed, with a cup of medications on his bedside table that contained three pills. Observation of the medication cup in Resident #72's room on 02/14/24 at 7:31 A.M. with Unit Manager/Licensed Practical Nurse (LPN) #804 confirmed there were three pills in the medication cup. LPN #804 identified two of the pills being Resident #71's thyroid medication but was unable to identify the third pill. LPN #804 stated she had educated the nursing staff on not leaving medications at the residents' bedside previously. Review of facility's undated policy titled Medication Administration revealed medications should not be left unattended. This deficiency represents non-compliance investigated under Complaint Number OH00151242.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident record review, printed meal ticket review, and policy review, the facility failed to ensure food was prepared in the correct form to meet resident needs. This affected one (#17) of one resident reviewed for appropriate diet texture. The facility census was 131. Findings include: Review of the medical record for Resident #17 revealed an admission date of 11/09/23 with diagnoses that included fracture of right femur, tracheostomy status, and dysphagia (difficulty swallowing) oropharyngeal stage. Review of the Diet History Food Preferences assessment dated [DATE] revealed Resident #17 had issues with swallowing and was on a pureed diet. Review of the physician orders dated 11/20/23 revealed Resident #17 had a current order for a regular diet, dysphagia pureed texture with nectar thick liquids consistency for nutrition. Review of the Dietary Nutritional assessment dated [DATE] revealed Resident #17 was on a pureed diet with a history of chewing and swallowing issues.…

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

Based on observation and staff and resident interview, the facility failed to maintain a sanitary and comfortable interior living environment. This affected seven residents (Resident #4, #16, #31, #38, #39, #78, and #103.) of the 125 residents living in the facility. Finding Include: 1. Observation on 10/17/23 at 8:15 A.M. of Resident #4's room revealed the heater unit on the floor had busted parts, was rusted and covered in dust. Three of three walls in the room were dirty with pealing paint and dried on staining from the ceiling to the floor. Interview with Resident #4 at the time of observation revealed she wished they would do something about the heater and dirty walls. 2. Observation on 10/16/23 at 5:03 P.M. of Resident #16's room revealed the bathroom door had four holes in the middle of the door and the privacy curtain had two holes in the top of the curtain. Interview at the time of observation with Resident #16 revealed the door had been that way since she moved into the room. 3. Observation on 10/16/23 at 11:52 A.M. of Resident #31's room revealed the television (TV) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility policy, observation and interivew, the facility failed to demonstrate appropriate use of Personal Protective Equipment (PPE) when entering and exiting the room of Resident #33 who resided on the second floor and was on transmission-based precautions for COVID-19. This had the potential to affect 46 residents (Resident #14, #78, #122, #100, #5, #53, #104, #113, #8, #16, #41, #29, #57, #81, #4, #10, #76, #63, #47, #46, #68, #89, #83, #112, #42, #24, #13, #18, #27, #55, #40, #30, #25, #6, #19, #38, #73, #98, #66, #32, #107, #90, #106, #31, #60, and #21 residing on the second floor. The facility census was 125. Findings include: 1. Record review for Resident #33 revealed an admission date of 05/04/21. Diagnosis included COVID-19 dated 10/12/23. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was moderately cognitively impaired and required extensive assistance of one staff for bed mobility, transfers, dressing and…

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

Based on record review, review of facility policy, observation and interview, the facility failed to timely address a change of condition for Resident #16. This affected one resident (Resident #16) of three residents reviewed for a change in condition. The facility census was 125. Findings include: Record review for Resident #16 revealed an admission date of 06/01/23 with diagnoses including hemiplegia and hemiparesis following a stroke affecting left non-dominant side, muscle weakness, and need for assistance with personal care. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/07/23, revealed Resident #16 was cognitively intact, dependent with toileting and personal hygiene and was always incontinent of bowel and bladder. Resident #16 had no ulcers, wounds, or other skin problems. Record review of the care plan dated 06/14/23 revealed Resident #16 had functional bowel and bladder incontinence. Interventions included checking resident for incontinence, wash, rinse, and dry perineum, observe for signs and symptoms of a urinary tract infection (UTI),…

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 record review, review of the facility policy, observation and interview, the facility failed to provided daily and as needed nail care to Resident #78 who required staff assistance with his activities of daily living (ADL). This affected one resident (Resident #78) of three residents reviewed for activities of daily living. The facility census was 125. Findings include: Record review for Resident #78 revealed an admission date of 04/29/21 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and need for assistance with personal care. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #78 was rarely or never understood. Resident #78 required extensive assistance of two for bed mobility, toilet use, personal hygiene, and extensive assistance of one for eating. Resident #78 had an indwelling catheter and was always incontinent of bowel. Record review of the care plan dated 05/07/21 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 observation, interview, record review, and review of the facility policy, the facility failed to ensure all smoking supplies were secured in a locked area when not in use by independent smokers. This affected two residents (Resident #106 and #65) of two residents reviewed for smoking. The facility identified 27 residents who independently smoked at the facility. The facility census was 125. Findings include: 1. Record review for Resident #106 revealed an admission date of 04/02/23. Diagnosis included nicotine dependence. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 was cognitively intact. Record review of the care plan dated 04/11/23 revealed Resident #106 utilized nicotine products. Interventions included: complete smoking evaluation and educate resident / resident representative to facility smoking policy. Record review of the smoking assessment dated [DATE] revealed Resident #106 was an independent smoker. Observation on 10/19/23 at 3:10…

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.

Based on record review, review of the facility policy and interview, the facility failed to follow the physician order for a gradual dose reduction (GDR) of a psychotropic medication as recommended by the licensed pharmacist for Resident #57. This affected one resident (Resident #57) of five residents reviewed for GDR of medications. The facility census was 125. Findings include: Record review for Resident #57 revealed an admission date of 12/29/20. Record review of the census revealed Resident #57 resided at the facility from 08/10/22 through 10/19/23 with no hospital or discharge transfers out of the facility. Record review of the care plan dated 10/16/23 revealed Resident #57 was at risk for falls secondary to a history of falls, receiving antianxiety and antidepressant medications. Interventions included to observe medication for side effects that may increase risk for falls. Review of the Pharmacist Recommendation for the Prescriber report, dated 07/18/23, completed by Consultant Pharmacist (CP) #602 revealed Resident #57 was recently documented for multiple falls. After a…

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 medical record review, facility policy review and interview, the facility failed to prevent a significant medication error for Resident #129, who had an admitting diagnosis of embolism and thrombosis of the iliac artery and history of deep vein thrombosis (DVT) in the bilateral lower extremities, when staff failed to administer Heparin (an anti-coagulant/blood thinner medication) according to the physician order. The facility also failed to notify the physician (PCP) and/or certified nurse practitioner (CNP) of missed doses of the medication. This affected one resident (#129) of six residents reviewed for medication administration. The facility census was 125. Findings include: Review of Resident #129's closed medical record revealed the resident was admitted to the facility for rehabilitation on 08/05/23 after being hospitalized from [DATE] due to a motorcycle accident requiring trauma intensive care and emergency surgery. Resident #129 was his own responsible party. Review of the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to refer the resident to the appropriate state-designated authority for Level II Pre-admission Screening and Resident Review (PASRR) evaluation and determination after the resident had a psychiatric hospitalization and subsequent new mental health diagnosis. This affected one Resident (Resident #84) of ten residents (Resident #16, #19, #50, #59, #61, #84, #93, #102, #110 and #147) reviewed for PASRR. The facility census was 150. Findings Include: Review of the medical record revealed Resident #84 was admitted on [DATE] with diagnoses including bipolar disorder, other schizophrenia and major depressive disorder. Review of the progress note dated 01/01/18 revealed Resident #84 had increased anxiety, suicidal ideation and complained of hearing voices in his head. On 01/02/18, Resident #84 was sent to the hospital for further evaluation, and on 01/03/18 was admitted to the psychiatric hospital. Resident #84 was subsequently readmitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices while passing a meal tray and cleaning a contact precaution room. This affected one resident (Resident #19) of two residents (Residents #19 and #148) reviewed for isolation precautions. Findings include: 1. Record review of Resident #19 revealed an initial admission date of 07/10/19. Diagnoses included: weakness, chronic obstructive pulmonary disease, and history of enterocolitis due to clostridium difficile (c diff). Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required extensive assistance of two staff for bed mobility, transfers, and toilet use, and was frequently incontinent of bowel and bladder. Review of February 2020 physician orders dated 02/10/20 revealed contact precautions every shift for diagnosis of rule out of c diff. Review of the care plan for Resident #19 with pending c. diff culture revealed interventions…

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.