Avalon By Otterbein At Perrysburg

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure active physician orders for the administration of oxygen therapy and further failed to ensure oxygen tubing was dated. This affected three (#1, #3, and #10) of three residents reviewed for oxygen use. The facility census was 58. Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 04/15/25. Diagnoses included chronic obstructive pulmonary disease (COPD) and a history of COVID-19. Review of the Minimum Data Set (MDS) assessment, accepted date of 08/14/25, revealed Resident #1 was cognitively intact and received oxygen therapy. Observations on 08/12/25 at 8:25 A.M. and at 4:45 P.M. revealed Resident #1 had a nasal cannula on, delivering oxygen at three liters per minute (lpm). Further observations revealed the oxygen tubing was not dated. Interview on 08/12/25 at approximately 5:10 P.M. with Assistant Director of Nursing (ADON) #604 verified Resident #1's oxygen tubing was not dated and it should have been. 2. 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 medical record review, review of the pharmacy Monthly Medication Reviews (MMR), review of the pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two (#4 and #48) of five residents reviewed for unnecessary medications. The facility census was 58.Findings include: 1. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #4 included Parkinson's disease, diabetes Type two, heart disease, and brief psychotic disorder. Review of Resident #4's Minimum Data Set, (MDS), dated [DATE], revealed the resident had mildly impaired cognition. Review of the pharmacy MMRs revealed the pharmacist reviewed Resident #4's medications on 01/18/25, 02/08/25, and 03/09/25, and made recommendations to the physician. Further review of Resident #4's medical record and the pharmacy recommendations revealed no evidence of what 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, staff interview, and review of manufacturer instructions, the facility failed to ensure insulin pens were disinfected prior to attaching the needle. This affected one (#27) of one resident reviewed for insulin administration. The facility census was 58.Findings include:Observation on 08/13/25 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #611 prepared Insulin Glargine and insulin aspart for administration to Resident #27. LPN #611 attached a needle to each insulin pen, without disinfecting the rubber stoppers of the insulin pen tips prior to attaching the needed, and proceeded to administer the medications as ordered. Interview on 08/13/25 at 8:08 A.M. with LPN #611 confirmed she did not disinfect the rubber stoppers of the insulin pen tips prior to attaching the needles.Interview on 08/13/25 at 8:15 A.M. with Assistant Director of Nursing (ADON) #604 revealed the rubber stoppers of insulin pen tips should have been disinfected prior to attaching the needles.Review of the manufacturer instructions for the insulin aspart pen delivery system revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and review of the facility policy the facility failed to notify a resident and their representative of a room change. This affected one resident, Resident #2, out of three residents reviewed for rooms changes. The current census is 55. Findings include: Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include acute respiratory failure with hypoxia, heart failure, diabetes type two, and absence of right lower leg. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and had no behaviors during the assessment period. Further review of Resident #2's medical record including scanned documented, progress notes, and assessments revealed no evidence of any notification of a room change. Interview on 05/02/25 at 9:50 A.M. with Resident #2 revealed the resident was pleasantly confused. Resident #2 stated she was unsure of any…

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, review of the facility recipes, and review of the facility menus, the facility failed to follow menus as planned by not following recipes, by not using portioned serving utensils, by not offering all menu items to each resident, and by not offering the main meal before offering a nutritionally unequal alternative. This affected Resident #5 and Resident #34 and had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #40, #42, #43, #46, #47, and #59) and House 3 (#1, #16, #18, #22, #26, #27, #37, #38, #48, and #49). The facility census was 58. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 12/10/18 with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all…

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

Based on observation, staff interview, review of the temperature logs, and review of facility policies, the facility failed to ensure refrigerator and dishwasher temperatures were monitored and documented, failed to ensure safe food storage, and failed to sanitize thermometers between food items. This had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #34, #40, #42, #43, #46, #47, and #59) , House 4 (#3, #9, #12, #17, #19, #21, #25, #39, #41, #52, #156, and #60), and House 5 (#2, #4, #13, #23, #35, #51, #157, #158, #159, #160, and #161). The facility identified all residents in these houses received food from the kitchen. The facility census was 58. Findings include: Interview on 02/20/24 at 8:34 A.M. with State Tested Nurse Aide (STNA) #302 revealed she did not know the process for documenting refrigerator and freezer temperatures. Interview and observation on 02/20/24 at 8:42 A.M. with STNA #317, in House 2, confirmed two containers of food labeled for Resident #59 were undated. One container contained deviled eggs with liquid around the bottom of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one (Resident #5) of two residents reviewed for catheter dignity. The facility identified three residents with indwelling catheters. In addition, the facility failed to provide a dignified dining experience to Resident #157 related to disposable dishware and utensils which had the potential to affect 11 additional residents in the 500 home (Residents #2, #4, #13, #23, #35, #51, #158, #159, #160, #161, and #162). The facility census was 58. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete a significant change assessment in the Minimum Data Set (MDS) when a resident was started on hospice. This affected one resident (#17) of two residents reviewed for hospice services. The facility census was 58. Findings include: Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #17 included anemia, dementia, chronic obstructive pulmonary disease, heart disease, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessments revealed there was no significant change assessments in the resident's medical records. Review of Resident #17's care plans dated 11/20/23 revealed the resident had a focus for hospice services relating to chronic obstructive pulmonary disease and dementia. Interventions were appropriate for the focus. Interview on 02/22/24 at 1:55 P.M. Licensed Practical Nurse (LPN) #311 revealed he was the facility's MDS nurse and responsible 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, staff interview, and record review, the facility failed to ensure dependent residents received assistance with nail care. This affected one (#43) of one resident reviewed for nail care. The facility census was 58. Findings include: Review of the medical record for Resident #43 revealed an admission date of 07/02/22 with diagnoses of anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and was dependent on staff for showering, bathing, and personal hygiene. Review of the current care plan for Resident #43 revealed she had an activities of daily life (ADL) deficit and required assistance from staff for care. An intervention included checking nail length, trimming and cleaning on bath day and as necessary. Observation on 02/20/24 at 9:58 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation 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, medical record review, staff interview, and review of facility policy, the facility failed to ensure ordered pressure ulcer reduction interventions were implemented as ordered. This affected one resident (#5) of three residents reviewed for pressure ulcer prevention. The facility census was 58. Findings include: Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Reviewed of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk…

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 video recordings, staff interview, record review, and review of a personnel file, the facility failed to appropriately transfer a resident using a mechanical lift. This affected one (#46) of one resident reviewed for transfers. The facility census was 58. Findings include: Review of the medical record for Resident #46 revealed an admission date of 01/20/23 with diagnoses of dementia and contractures of both knees. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was rarely/never understood and was dependent on staff for transfers. Review of the current care plan revealed Resident #46 required a mechanical lift with two staff for transfers. Further review revealed Resident #46 used an electronic video and/or audio monitoring device in her private room. Observation on 02/20/24 at approximately 10:40 A.M. revealed a sign inside Resident #46's door indicating voice and video recordings were in use. Review of video footage provided by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facilities bowel regime for constipation, the facility failed to ensure a resident received care and interventions for constipation. This affected one resident (#18) of two residents reviewed for bowel and bladder. The facility census was 58. Findings include: Review of Resident #18's medical record revealed an admission date of 05/22/20. Diagnoses included muscle weakness, symbolic dysfunction, constipation, dementia, major depressive disorder, anxiety disorder, insomnia, and restlessness and agitation. Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of eight, indicating Resident #18 was moderately cognitively impaired. Resident #18 was dependent on staff for toilet use, bathing, dressing and personal hygiene. Resident #18 displayed verbal behavioral symptoms directed toward others four to six days during the review period. Review of Resident #18's care plan revised 01/24/24…

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 clarification was received and physician orders were implemented. This affected one resident (#19) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Record review for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 include chronic respiratory failure, seizures, chronic kidney disease, and dementia with psychosis. Review of Resident #19's care plans dated 06/12/22 revealed a focus for impaired cognitive function related to dementia, short term memory loss and long term memory loss. Interventions include administer medications per physician order. Review of Resident #19's care plans dated 05/11/22 revealed a focus for antipsychotic medication use. Interventions include administer medications per physician order, consult with pharmacy and with physician to consider dosage reduction when clinically appropriate or at least…

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 pharmacy recommended and physician approved laboratory (lab) orders were completed as recommended. This affected one resident (#5) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Reviewed of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, potential…

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, record review, and review of the facility policy, the facility failed to ensure pharmacy recommendations for gradual dose reductions for psychotropic medications were addressed. This affected two (#43 and #19) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 07/02/22 with diagnoses of anxiety and depression. Resident #43 was under hospice care since 07/25/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and received antianxiety and antidepressant medications. Review of a physician order dated 07/25/22 revealed Resident #43 received lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every four hours as needed. Review of a physician order dated 11/11/22 revealed Resident #43 received buspirone (an antianxiety medication), 2.5 mg by mouth twice daily. Review of 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.

Based on observation, staff interview, and review of the policy for medication storage, the facility failed to ensure medication carts were secured and medications were placed in the medication cart. This affected two (Residents #29 and #34) of two residents observed for medication administration. The facility census was 58. Findings include: 1. Observation of medication pass on 02/20/24 at 4:00 P.M. with Licensed Practical Nurse (LPN) #366 with Resident #29, revealed LPN #366 prepared the correct amount of Humalog into the syringe. LPN #366 placed the Humalog on top of the medication cart. LPN #366 followed Resident #29 into his room and shut the door to inject his insulin in his abdomen. LPN #366 was not in direct sight of the medication cart which was not secured and the insulin was left on top of the medication cart. Interview with LPN#366 on 02/20/24 at 4:08 P.M. verified he left the medication of Humalog on top of the unsecured medication cart and should have put back into the cart and secured the cart. 2. Observation of medication pass on 02/20/24 at 4:44 P.M. with LPN #378…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure food intolerance's were honored at meals. This affected one (#5) of one resident reviewed for meal intolerance's. The facility census was 58. Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/10/18 with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of the current physician order dated 01/08/24 revealed Resident #5 received regular diet with pureed texture and thin liquids. Review of the allergies documented in the electronic medical record for Resident #5 revealed lactose intolerance was added to his profile on 04/05/23. Review of the meal intake…

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

Based on review of staffing schedules and staff interview, the facility failed to provide a Registered Nurse (RN) at least eight hours daily in the facility. This had the potential to affect all 49 of 49 residents in the facility. The facility census was 49. Findings include: Review of the staffing schedules revealed the facility did not have a RN work eight hours on 12/04/21, 12/05/21, 12/19/21 and 12/26/21. Interview on 12/29/21 at 12:15 P.M., with the DON verified the facility did not have a RN on duty eight hours on 12/04/21, 12/05/21, 12/19/21 and 12/26/21. The DON denied having a policy for staffing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to provide urinary catheter care. This affected four (#3, #45, #48 and #145) of four residents reviewed for urinary catheters. The facility identified four residents with indwelling urinary catheters. The facility census was 49. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/20/15. Diagnoses included unspecified dementia without behavioral disturbance, retention of urine, essential hypertension, major depressive disorder, recurrent, anxiety disorder, neuromuscular dysfunction of bladder and heart failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) score of 13 out of 15. Resident #3 had an indwelling catheter and was always continent of bowel. Review of the care plan dated 09/18/17 revealed Resident #3 had a Foley urinary catheter 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.

Based on medical record review, policy review, staff and resident interviews, the facility failed to provide a written copy of the baseline care plan to a resident. This affected one (#145) of three sampled residents reviewed for baseline care plans. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set had not been completed at this time. Further review revealed a baseline care plan dated 12/26/21 had been completed. There was no documentation that the resident received a copy of the baseline care plan. Interview on 12/29/21 at 12:52 P.M., with Resident #145 revealed he had not received a copy of his baseline care plan. Resident #145 stated he had not signed any type of care plan since he had been at the facility. Interview on 12/29/21 at 8:47 A.M., with Licensed Practical Nurse (LPN) #436 verified Resident #145 had not received a copy…

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, staff interview, and policy review, the facility failed to develop a comprehensive plan of care to address a resident's communication needs. This affected one (#27) of 15 residents reviewed for care planning. The facility census was 49. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included hearing loss, asthma, major depressive disorder, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was moderately cognitively impaired. Review of the plan of care, revised 12/28/21, revealed Resident #27 had a communication problem related to poor hearing. Additionally, Resident #27 read lips, would do a thumbs up or down to indicate likes and dislikes. Interventions included using a thumbs up and down and a dry erase board. Observation on 12/27/21 at 10:28 A.M., of Resident #27 revealed the resident in bed watching television. A sign was hanging in the resident's…

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

Based on medical record review, observation, staff interview and policy review, the facility failed to provide dressing changes as ordered and apply compression stockings to the legs. This affected one (#145) of one resident reviewed for wound care and compression stockings. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set was not completed at this time. Review of the baseline care plan dated 12/26/21 revealed Resident #145 had no care plan to address wound care or application of compression stockings. Review of the hospital discharge physician orders dated 12/26/21 revealed Resident #145 had an order to cleanse abdomen and lower back with normal saline and place dry ABD pad daily, until no drainage then leave open to air one time a day for dressing change and compression sock to right lower extremity on in morning and off at night.…

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, staff interview and policy review, the facility failed to provide care and services for a resident's Peripheral Inserted Central Catheter (PICC) intravenous line. This affected one (#145) of one resident reviewed for intravenous therapy. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set was not completed at this time. Review of the care plan dated 12/26/21 revealed Resident #145 received Intravenous (IV) antibiotic therapy. Resident will not experience complications related to IV therapy. Change my IV primary and secondary tubing per protocol. Flush my peripheral, PICC (peripheral inserted central catheter), or midline per protocol. The care plan did not include interventions for wound care. Review of the hospital discharge physician orders dated 12/26/21 revealed Resident #145 had an order for heparin…

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 and staff interview, the facility failed to store oxygen tubing in a sanitary manner and failed to have a system in place to ensure oxygen tubing was changed regularly. This affected two (#2 and #42) of two residents reviewed for oxygen administration. The facility identified eight residents who received oxygen therapy. The facility census was 49. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 04/21/18. Diagnoses included respiratory failure, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. Review of the plan of care, initiated 03/27/19 revealed Resident #2 had oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal prongs at 1-2 liters (L) as needed. Review of a physician order 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.

Based on medical record review, observation, resident interview, staff interview and policy review, the facility failed to provide pain management to a resident. This affected one (#145) of two residents reviewed for pain management. The facility identified 30 residents that receive pain management. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set (MDS) assessment was not completed at this time. Review of the care plan dated 12/26/21 revealed the resident had pain related to osteoarthritis. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain within a reasonable amount of time after approach through the review date. Administer analgesia as per orders. Give one half hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to reassess a resident for continued use of enabler bars according to the facility policy. This affected one (#2) of one resident reviewed for potential restraint. The facility census was 49. Findings include: Review of the medical record for Resident #2 revealed an admission date of 04/21/18. Diagnoses included respiratory failure, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and required extensive two-person assistance with bed mobility and transfers. Review of the plan of care, revised 06/17/19, revealed Resident #2 had an Activities of Daily Living (ADL) mobility performance deficit related to diabetes, contractures to the bilateral lower extremities, and COPD. Interventions included bilateral side enabler bars…

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

Based on medical record review, observation, staff interview, resident interview and policy review, the facility failed to provide an antibiotic and pain medication to a resident. This affected one (#145) of five residents reviewed for medication administration. The facility identified 30 residents that receive pain medications and two residents receive antibiotics. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set assessment was not completed at this time. Review of the discharge physician orders from the hospital dated 12/26/21 revealed an order for oxycodone-acetaminophen 5-325 milligram (mg) one tablet by mouth every six hours as needed for pain until 01/02/22, pregabalin 100 mg one tablet every eight hours for muscle pain and ceftriaxone sodium solution reconstituted two gram intravenous (IV) one time a day for infection until…

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 policy review, the facility failed to ensure a PRN (as needed) order for a psychotropic medication did not exceed 14 days and the facility failed to perform a quarterly Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving psychotropic medication. This affected two (#24 and #36) of five residents reviewed for unnecessary medications. The facility identified 33 residents that receive psychotropic medications. The facility census was 49. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 11/10/21. Diagnoses included weakness, essential hypertension, nonrheumatic mitral valve insufficiency, sick sinus syndrome, atrial flutter, presence of cardiac pacemaker, pulmonary hypertension, type 2 diabetes mellitus with diabetic neuropathy and unspecified dementia without behavioral disturbance. Review of the quarterly Minimum Data Set Assessment revealed Resident #24 had moderate cognitive impairment…

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 of medication supplies, manufacturer instruction reviews and staff interview, the facility failed to ensure open dates were marked on insulin products in use. This affected two (#23 and #17) of two resident's insulin medication observed . The facility identified 13 residents with orders for insulin administration. The census was 49. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 12/19/20. Diagnoses included Type 2 diabetes mellitus. Review of physician orders for Resident #23 revealed they included an order dated 08/18/21, for Lantus (Basaglar) SoloStar 100 units per milliliter insulin solution pen injector, inject 22 units twice daily. Observation on 12/29/21 at 7:30 A.M., revealed the medication storage cart in House #1 contained two Basaglar (Lantus) 100 units per milliliter insulin Kwikpens for Resident #23, with one approximately three-quarters full and the other one approximately two-thirds full. Neither pen was marked with an open date. Interview during this observation with Registered Nurse #434 confirmed…

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.