Majestic Care Of Perrysburg

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure non-pressure ulcer wound care was initiated timely upon admission and completed as ordered. This affected two (#1 and #55) of three residents reviewed for wound care. The facility census was 52.Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 03/12/26 with diagnoses including subsequent encounter of bladder injury, septic shock, ascites, Type Two diabetes mellitus, polyneuropathy, irritable bowel syndrome, cystocele, peritonitis and stage three chronic kidney disease.Review of the admission Minimum Data Set (MDS) assessment, dated 03/19/26, revealed Resident #1 was cognitively intact and did not display any behaviors nor refusals of care at the time of this assessment. She required maximal assistance to full dependence with activities of daily living (ADLs), bed mobility, and transfers. Resident #1 utilized a wheelchair and was depended for mobility.Review of the current care plan for Resident #1 revealed interventions for skin…

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 timely assessment and preventative interventions were implemented for a diabetic foot ulcer. This affected one (#47) of one resident reviewed for diabetic foot care. The facility census was 52. Findings include:Review of Resident #47's medical record revealed an admission date of 05/20/20 with diagnoses including schizoaffective disorder, Type II diabetes mellitus, history of diabetic ulcers, dementia, peripheral vascular disease, hypertension, chronic pain syndrome, insomnia, and hypothyroidism.Review of the Minimum Data Set (MDS) assessment, dated 03/12/26, revealed Resident #47 was assessed with moderately impaired cognition, no recorded resistive behaviors, required setup or clean-up assistance with eating, was dependent for activities of daily living (ADLs), required substantial to maximal assistance with bed mobility and was not at risk of developing pressure ulcers with a diabetic foot…

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

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure hemodialysis access sites were properly assessed and monitored. This affected one (#7) of one resident reviewed for dialysis care. The facility census was 52. Findings include:Review of Resident #7's medical record revealed an admission date of 10/06/20. Diagnoses included end stage renal disease, dependence on renal dialysis, arteriovenous fistula, hypertension, malnutrition, hydronephrosis, hypotension, major depression, malignant neoplasm of prostate, and anemia.Review of the Minimum Data Set (MDS) assessment, dated 01/14/26, revealed Resident #7 was assessed with intact cognition and received dialysis. Review of the care plan, dated 01/15/24, revealed Resident #7 received hemodialysis related to (r/t) end stage renal disease (ESRD). Interventions included: left arm fistula; hemodialysis on Tuesday, Thursday and Saturday with usual chair time at 6:00 A.M.; will have no signs/symptoms of complications from dialysis treatments through the review date; monitor left arm…

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

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames for five of 32 observed medications administered, resulting in a 15.63% medication error rate. This affected one (#47) of four residents reviewed for medication administration. The facility census was 52. Findings include:Observation on 04/13/26 at 11:22 A.M. revealed Licensed Practical Nurse (LPN) #145 prepared Resident #47's medications for administration. Medications included the following: cephalexin 500 milligrams (mg) one tablet, Austedo 12 mg one tablet, Risperdal 0.25 mg one tablet, metoprolol tartrate 50 mg one tablet, and an insulin glargine pen set with 10 units. Continued observation revealed LPN #145 entered Resident #47's room at 11:25 A.M. and administered the medications, including 10 units of insulin via subcutaneous injection to the resident's right upper extremity.Review of Resident #47's medical record revealed the resident had the following…

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

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure insulin was administered in accordance with physician orders. This affected one (#47) of four residents reviewed for medication administration. The facility census was 52. Findings include:Observation on 04/13/26 at 11:22 A.M. revealed Licensed Practical Nurse (LPN) #145 prepared Resident #47's medications for administration. Medications included the following: cephalexin 500 milligrams (mg) one tablet, Austedo 12 mg one tablet, Risperdal 0.25 mg one tablet, metoprolol tartrate 50 mg one tablet, and an insulin glargine pen set with 10 units. Continued observation revealed LPN #145 proceeded to Resident #47's room at 11:25 A.M. and administered the medications, including 10 units of insulin via subcutaneous injection to the right upper extremity. Review of Resident #47's medical record revealed the resident had the following physician medication orders: cephalexin 500 mg, give one tablet by mouth two times a day for wound infection seven days with administration…

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, medical record review and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (#4) of four residents reviewed for medication administration. The facility census was 52.Findings include:Review of Resident #4's medical record revealed an admission date of 01/25/21 with diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, Type II diabetes mellitus, bipolar disorder, major depression, anxiety disorder, neuropathy, restless leg syndrome, anemia, chronic viral hepatitis c, transient ischemic attack, and hypertension.Review of the Minimum Data Set (MDS) assessment, dated 03/26/26, revealed Resident #4 was assessed with intact cognition and required setup/clean-up assistance with activities of daily living. Resident #4 received antianxiety, antidepressant, anticoagulant, diuretic, opioid, antiplatelet, hypoglycemic and anticonvulsant medications. Observation on 04/14/26 at 7:42 A.M. revealed Licensed Practical Nurse (LPN) #130 prepared 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 closed medical record review, staff interviews and review of facility policy, the facility failed to ensure complete and accurate documentation in the medical record. This affected one (#59) of three residents reviewed for accurate medical records. The facility census was 52. Findings include:Review of the closed medical record for Resident #59 revealed an admission date of 11/21/25 and a discharge date of 02/10/26. Diagnoses included traumatic subdural hemorrhage, intracranial abscess and granuloma and dependence on respirator (ventilator) status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/06/26, revealed Resident #59 had impaired cognition. Further review revealed a Discharge Return Anticipated MDS was completed on 02/10/26. Review of the facility's Admission, Discharge, and Transfer Report, from 02/01/26 through 02/28/26, revealed Resident #59 was discharged to the hospital on [DATE]. Interview on 04/15/26 at 12:10 P.M. with the Interim Director of Nursing (IDON) 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, observation, interview, and policy review, the facility failed to ensure a call light was within reach. This affected one (#46) of six residents reviewed for call lights. The facility census was 55.Findings include:Review of the medical record for Resident #46 revealed an admission date of 01/13/25 with diagnoses including but not limited to adult failure to thrive, hemiplegia/hemiparesis affecting non-dominant left side, and major depressive disorder.Review of The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living with the exception of eating.Review of the care plan dated 10/08/25 revealed the resident is at risk for falls related to decline in functional mobility, stroke with left sided weakness, and non-ambulatory status. Interventions included ensure call light is within reach and encourage resident to use it for assistance as needed.Observation and interview 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 record review, interview, and policy review, the facility failed to report an allegation of an injury of unknown origin to the State Agency. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and use caution during transfers and bed mobility to prevent striking arms, legs, 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, interview, and policy review, the facility failed to investigate a injury of unknown origin. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.Findings include:Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against…

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 care plans were implemented and contained resident specific goals and preferences regarding discharges. This affected two (#53 and #54) of seven residents reviewed for care plans. The facility census was 51.Findings include:1. Review of the medical record for Resident #53 revealed an admission date of 06/02/25 and discharge date of 08/01/25. Diagnoses included but were not limited to hypertension, congestive heart failure, chronic pain disorder, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact.Review of the care plan dated 06/03/25 revealed Resident #53's discharge plan included interventions for social services to assist with discharge planning. The care plan was not specific to the resident's preference and potential for future discharge and lacked evidence the facility determined the resident's desire to return to 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 policy review, the facility failed to ensure falls were thoroughly investigated to determine a root cause, documented in the medical record, and immediate interventions were put in place which were appropriate. This affected three (#5, #13, and #54) of three residents reviewed for falls. The facility census was 51.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 12/08/23 with diagnoses including but not limited to dementia mild with agitation, syncope and collapse, muscle weakness, difficulty walking, and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment and required supervision or touching assistance for bed mobility, transfers, and ambulation.Review of the care plan dated 09/03/25 revealed Resident #5 was at risk for falls related to dementia, side effects of medications, diagnosis of syncope and collapse, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, review of meal tickets, resident and staff interview, and policy review, the facility failed to ensure nutritional assessments were completed timely to determine dietary preferences and failed to ensure food preferences were honored. This affected two (#32 and #54) of four residents reviewed for nutrition. The facility census was 51.Findings include:1. Review of the medical record for Resident #32 revealed an admission date of 02/27/25 with diagnoses including but not limited to congestive heart failure, Parkinsonism, type two diabetes mellitus, weakness, hypertension, and malignant neoplasm of the prostate.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment.Review of a care plan dated 02/27/25 revealed Resident #32 presented with a potential nutritional risk related to a therapeutic diet and diabetes with interventions included to honor food/fluid preferences, and provide and serve diet as ordered.…

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 interviews, wound clinic staff interview, and review of facility policy, the facility failed to ensure wound care treatments and follow-up appointments were completed as ordered. This affected three (#127, #134, and #160) of four residents reviewed for wound care. The facility census was 58.Findings include:1. Review of the medical record for Resident #127 revealed he was admitted on [DATE] with diagnoses that included atherosclerotic heart disease, peripheral vascular disease, hypertension, and atherosclerosis of native arteries of the left leg with ulceration of the heel and midfoot. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and did not refuse care. Review of the current care plan for Resident #127 revealed Resident #127 had an open chest lesion. The interventions included treatment to chest per orders.Review of the physician orders and treatment administration records (TAR) for Resident #127 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, staff interview, and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected two (#134 and #140) of four residents reviewed for wound care. The facility census was 58.Findings include:1. Review of the medical record for Resident #134 revealed he was admitted on [DATE] with diagnoses that included disorder of lipoprotein, myelodysplastic syndrome (disorder affecting bone marrow), and non-pressure chronic ulcer of the right heel and midfoot with the fat layer exposed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was moderately cognitively impaired, and he did not refuse care.Review of the current care plan for Resident #134 revealed he had impaired skin integrity. The interventions included wound treatment as ordered.Review of the physician orders and treatment administration records (TAR) for Resident #134 revealed orders beginning on 06/21/25 for daily wound care 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 observation, staff interview, review of pest control service records, and policy review, the facility failed to ensure the facility was free of ants. This affected five residents (#20, #25, #6, #41, #27) and the potential to affect an additional 13 residents (#2, #7, #8, #11, #13, #14, #18, #21, #22, #30, #32, #36, #47) residing on the 400 hall. The facility census was 46. Findings include: Review of the pest control service records revealed the facility had not received preventative pest control treatments since 08/21/24. No pest control services were provided in 09/2024, 10/2024, and 11/2024. Additionally, no pest control services were provided in the facility from 12/01/24 through 12/15/24. Observation on 12/16/24 at 8:04 A.M., in Resident #25's room revealed there approximately 12 ants on the floor near the wall. Observation on 12/16/24 at 8:06 A.M. in the shared room of Resident #27 and Resident #41 revealed there were approximately 15 ants on the floor near the wall. Observation on 12/16/24 at 8:07 A.M. in Resident #6's room revealed there was one ant on the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a wound care treatment progress note, review of physician orders, observation, staff interview, and policy review, the facility failed to correctly identify the type and location of a wound. Additionally, the facility failed to ensure wound care treatments were completed per physician orders. This affected one (#30) of three residents reviewed for wound care. The facility identified seven residents requiring wound care management. The facility census was 46. Findings include: Review of the medical record for Resident #30 revealed an admission date of 10/19/19. Diagnoses included multiple sclerosis, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent for toileting hygiene and personal hygiene. Review of a nurse's progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided timely. This affected one (#30) of three residents reviewed for incontinence care. The facility census was 46. Findings include: Review of the medical record for Resident #30 revealed an admission date of 10/19/19. Diagnoses included multiple sclerosis, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting hygiene and personal hygiene. Review of the plan of care dated initiated 09/14/20 revealed the resident was incontinent related to multiple sclerosis and weakness. Interventions noted the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of physician orders, review of the medication administration record, review of a pharmacy invoice, review of contingency medication supply records, staff interview and policy review, the facility failed to timely clarify physician orders and ensure medications were administered per physician orders. This affected one resident (#50) of three residents reviewed for medication administration. The facility census was 49. Findings include: Review of the medical record for Resident #50 revealed an admission date of 06/30/24 and a discharge date d of 07/25/24. Diagnoses included cirrhosis of the liver, hepatic encephalopathy, hypertension, peripheral vascular disease, diabetes mellitus type two, fibromyalgia and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment. Review of the hospital discharge medication orders dated 06/30/24 revealed Resident #50 was ordered pregabalin (Lyrica) 50 milligrams (mg) three times a day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to maintain resident dignity when dining. This affected five (#9, #21, #30, #32, and #51) of 13 residents observed during meals. The census was 50. Findings Include: 1. Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included hypercholesterolemia, hypotension, generalized anxiety disorder (GAD), muscle weakness, other abnormalities of gait and mobility, difficulty in walking, cognitive communication deficit, personal history of COVID-19, and pain. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 03/06/24, for Resident #32 revealed the resident was severely cognitively impaired and required supervision or touching assistance with eating. Review of the most recent care plan revealed Resident #32 was identified to have behaviors of throwing non-disposable cutlery and dishes in the garbage. Interventions, dated 09/16/22 and resolved 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 and staff interview, the facility failed to ensure resident wheelchairs were kept in a clean and sanitary manner. This affected three (#25, #32 and #43) of three residents reviewed for wheelchairs. The census was 50. Findings include: 1. Review of the medical record revealed Resident #25 was admitted on [DATE] with a re-admission date of 02/16/23. Diagnoses included multiple sclerosis, vascular dementia severity with agitation, type two diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and other abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) assessment, dated 01/19/24, revealed Resident #25 was assessed with moderate cognitive impaired and used a wheelchair. Observation on 03/25/24 at 9:42 A.M. with Resident #25 revealed the resident was in his wheelchair and the wheelchair had a thick build-up of dirt and debris along the outside. Observation on 03/27/24 at 3:53 P.M. 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, observation, staff and resident interview, and facility policy review, the facility failed to maintain proper infection control practices when providing care and services. This affected four (#18, #26, #37, and #48) of 14 residents observed receiving care and services from staff. The facility census was 50. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 09/29/20 with diagnoses of hypertension, gastroesophageal reflux, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. Review of Resident #18's current physician orders upon entrance on 03/25/24 revealed an order for the antibiotic Augmentin every twelve hours from 03/04/24 to 03/11/24, and contact precautions for a urinary tract infection with extended spectrum beta lactamase (ESBL) and Escherichia coli (E-coli). Observation on 03/25/24 at 12:08 P.M. revealed as State Tested…

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 resident funds accounts, fund balance notification documents, medical record review, and staff interview, the facility failed to ensure notifications of funds in excess of the Medicaid limit were followed up with timely notification and assistance to lower the fund balance. This affected three residents (#03, #24 and #27) of five reviewed for personal funds. The facility census was 50. Findings Include: 1. Review of Resident #03's personal funds account revealed a balance of $3,277.29 on 03/31/23, a balance of $3,349.38 on 06/30/23, a balance of $3,412.47 on 09/29/23, a balance of $3,502.56 on 12/29/23, and a balance of $3,529.60 on 03/26/24. Further review revealed the facility sent a document titled, Resident Fund Balance Notification, on 01/23/24 and 03/22/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no record of a discussion with the representative located in Resident #03's medical record. 2. Review of Resident #24's personal…

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 a comprehensive assessment was completed timely after a significant change in a resident's status. This affected one (#47) of 14 residents reviewed for assessments. The facility census was 50. Findings include: Review of the medical record for Resident #47 revealed an admission date of 08/03/23 with diagnoses of congestive heart failure and hemiplegia and hemiparesis affecting the left non-dominant side. Review of Resident #47's physician orders revealed an order dated 09/07/23 to admit Resident #47 to hospice with a diagnoses of diastolic heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a comprehensive assessment was completed due to a significant change in Resident #47's status. Interview on 03/27/24 at 4:05 P.M. with Regional Support Registered Nurse #90 confirmed Resident #47 was admitted to hospice on 09/07/23 and a significant change comprehensive MDS assessment was not completed 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, hospital documentation review, staff interview, and review of a facility policy, the facility failed to develop a care plan with appropriate interventions when a resident was readmitted to the facility with a new diagnosis following a hospitalization. This affected one resident (#42) of 14 residents reviewed for care plans. The facility census was 50. Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/05/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hypertension, heart failure, and dementia. On 02/20/24 a diagnoses was added to include a subdural hematoma (a collection of blood between the brain and its outermost cover) when the resident was re-admitted to the facility from a hospitalization. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with cognitive impairment and was dependent on staff for activities of daily living. 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 medical record review, staff interview, and review of a facility policy, the facility failed to ensure laboratory tests were completed as ordered by the physician. This affected one (#42) of six residents reviewed for laboratory testing. The facility census was 50. Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/05/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hypertension, heart failure, and dementia A diagnosis of a subdural hematoma (a collection of blood between the brain and the outermost cover) was added on 02/20/24 when the resident was readmitted from a hospitalization. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with cognitive impairment and was dependent on staff for activities of daily living. Review of the hospital discharge record for continuation of care printed on 02/20/24 at 6:11 P.M. revealed Resident #42 was discharged back to 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, hospital documentation review, and staff interview, the facility failed to ensure diagnostic services were provided as ordered. This affected one resident (#42) of 14 residents reviewed for care and services. The facility census was 50. Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/05/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hypertension, heart failure, and dementia. On 02/20/24 a diagnoses was added to include a subdural hematoma (a collection of blood between the brain and its outermost cover) following a readmission to the facility from a hospitalization. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with cognitive impairment and was dependent on staff for activities of daily living. Review of the progress notes dated 02/17/24 at 3:32 A.M. revealed Resident #42 was sweaty and difficult to arouse, so the physician 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 review of staffing schedules, review of daily posted staffing information, staff interview, and policy review, the facility failed to ensure a Registered Nurse (RN) was present in the facility eight hours per day, seven days per week. This had the potential to affect all residents. The facility census was 52. Findings include: Review of the daily staffing schedules and daily posted staffing documentation from 02/01/24 through 03/03/24 revealed there was no RN coverage in the facility on 02/04/24, 02/10/24, 02/17/24, 02/25/24, 03/02/24, and 03/03/24. Interview on 03/05/24 at 12:18 P.M., the Administrator revealed the only RN employed by the facility was the Director of Nursing. The Administrator verified there was no RN coverage in the building on 02/04/24, 02/10/24, 02/17/24, 02/25/24, 03/02/24, and 03/03/24. Review of the policy titled, Nursing Department Guidelines, last revised 11/2022 revealed the facility would staff a RN eight consecutive hours seven days a week. This deficiency represents non-compliance investigated under Master Complaint Number OH00151286.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of a risk alert document, review of fall investigations, observation, interview, and policy review, the facility failed to ensure a thorough investigation was completed to determine how a resident exited the facility through a locked door in the memory care unit. This affected one (Resident #21) of three residents reviewed for elopement. The facility identified five residents (#21, #34, #40, #50 #51) at risk for elopement. Additionally, the facility failed to complete a thorough falls investigation and implement new fall prevention interventions to potentially prevent additional falls for one resident. This affected one (Resident #27) of three residents reviewed for falls. The facility census was 52. Findings include 1. Review of the medical record revealed Resident #21 had an admission date of 06/09/23. Diagnoses included Alzheimer's disease, chronic pain, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] 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 medical record review, staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure pneumococcal vaccines were offered to residents per CDC recommendations. This affected four (#40, #43, #51, and #54) of five residents reviewed for pneumococcal vaccination. Additionally, the facility failed to provide vaccination education to one (#11) of five residents reviewed for pneumococcal vaccinations. The facility census was 56. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 09/20/22. Diagnoses included end stage renal disease and acquired absence of other organs. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 10/08/23, revealed Resident #11 had intact cognition. Review of the immunization record in the electronic medical record (EMR) revealed Resident #11 refused the pneumococcal vaccine. No date of refusal was documented in the record and there 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility policy, and review of a Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure COVID-19 vaccination booster doses were offered to residents. This affected two (#11 and #51 ) of five residents reviewed for COVID-19 vaccination booster status. The facility census was 56. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 09/20/22. Diagnoses included end stage renal disease and acquired absence of other organs. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Review of the immunization record in the electronic medical record (EMR) revealed no evidence Resident #11 was offered the COVID-19 Bivalent Booster. 2. Review of the medical record for Resident #51 revealed an admission date of 01/25/21. Diagnoses included chronic obstructive pulmonary disease and type II diabetes mellitus. Review of the…

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

Based on review of staff schedules, review of facility documentation, staff interview, and review of facility policy, the facility failed ensure registered nurse (RN) services were utilized at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 53 residents residing in the facility. Findings include: Review of the staffing schedule, dated 08/20/23 to 08/26/23, revealed all the nursing staff were licensed practical nurses (LPN) with the exception of RN #204, who was scheduled for orientation for six hours on 08/20/23. Review of the facility provided document revealed on a rotational basis a Corporate RN was utilized in the building Monday through Friday. There was no RN coverage on the weekend. Interview on 08/30/23 at 4:14 P.M. with Scheduler #202 revealed all nurses employed at the facility were LPN and did not have any RN to fill in the schedule resulting in no RN coverage on the weekend. Review of the facility policy titled Nursing Department Staffing Guidelines, revised November 2022, revealed the facility will staff a RN 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.

Based on observation, staff interview, medical record review, and review of manufacturer instructions, the facility failed to ensure medications were administered per manufacturer instructions, resulting in a medication error rate of five percent (%) or greater. There were three medication errors out of 31 opportunities, resulting in a medication error rate of 9.68%. This affected two (Residents #11 and #48) of four residents reviewed for medication administration. The facility census was 53. Findings include: 1. Review of the physician orders dated 03/08/23 revealed Resident #48 had an order to obtain a fingerstick blood sugar before meals (AC) and at bedtime (HS). On 04/19/23, the physician order was to administer 34 units of insulin via Humalog Kwik Pen Solution Pen-injector subcutaneously before meals and at bedtime for diabetes; give 32 units along with sliding scale coverage with lunch and dinner and 14 additional units with nighttime snack. In addition, on 04/19/23, the physician ordered insulin sliding scale to include via Humalog Kwik Pen Solution Pen-injector…

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

Based on observations, staff interviews, medical record reviews, and review of manufacturer instructions, the facility failed to ensure the administration of insulin medications were provided in accordance with instructions for use which resulted significant medication errors and potential dosage errors. This affected two (Residents #11 and #48) of four residents reviewed for medication administration. The facility census was 53. Findings include: 1. Review of the physician orders dated 03/08/23 revealed Resident #48 had an order to obtain a fingerstick blood sugar before meals (AC) and at bedtime (HS). On 04/19/23, the physician order was to administer 34 units of insulin via Humalog Kwik Pen Solution Pen-injector subcutaneously before meals and at bedtime for diabetes; give 32 units along with sliding scale coverage with lunch and dinner and 14 additional units with nighttime snack. In addition, on 04/19/23, the physician ordered insulin sliding scale to include via Humalog Kwik Pen Solution Pen-injector subcutaneously before meals and at bedtime. Sliding scale dosages were as…

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 interview, and staff interview, the facility failed to serve meals in a dignified manner by serving meals on disposable dishware and cutlery. This had the potential to affect all residents except for Residents #26, #27, #30, #36, #39, #40 who did not identify dignity concerns and Residents #197 and #198 identified by the facility as residents who did not receive food from the kitchen (did not eat by mouth). The facility census was 47. Findings include: Observation on 03/28/22 at 8:41 A.M. of the memory care unit dining room revealed residents eating breakfast. Breakfast was served in Styrofoam containers. Beverages, with the exception of coffee, was served in Styrofoam cups, and residents had plastic cutlery. Observation on 03/29/22 at 8:43 A.M. of the East Wing breakfast tray service revealed meals were served in Styrofoam containers, beverages were served in Styrofoam cups, and plastic cutlery was provided to residents. Observation on 03/29/22 at 12:00 P.M. of the East Wing lunch tray service revealed meals were served in Styrofoam containers,…

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 Resident Trust Account Authorizations, facility policy, and staff interview, the facility failed to ensure residents had reasonable access to personal funds. This affected Residents #2, #3, #4, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43 identified by the facility as having Resident Trust Accounts. In addition, the facility failed to have signed witnessed authorizations for two (#15 and #20) of five residents reviewed for personal funds. The facility census was 47. Findings include: 1. Interview on 03/31/22 at 1:40 P.M. Receptionist #550 reported the facility did not have a business office manager and she managed resident's personal funds at the facility. Receptionist #550 stated residents were able to come to her Monday through Thursday from 8:30 A.M. until 3:30 P.M. and on Fridays from 8:30 A.M. until 3:00 P.M. Receptionist #550 stated the facility did not have another designated person for residents to go to to get money. Receptionist #550…

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 policy for wound care, policy for falls, and policy for neurological assessments, the facility failed to provide non-pressure wound care as ordered for two (Residents #27 and #45) of three residents reviewed for wound care, failed to conduct neurological assessments for two (Residents #15 and #42) of three residents reviewed for falls, and failed to complete post fall assessments for one (Resident #42) of three residents reviewed for falls. The facility census was 47. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #45 included osteomyelitis, chronic respiratory failure, infection in surgical wound, malnutrition, hernia, stage IV pressure ulcer of sacrum, sepsis, and spinal stenosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition, was a one person physical assist with ADLs, had one unstageable…

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

Based on observation, medical record review, staff interview, review of Safety Data Sheets, and review of facility policy, the facility failed to secure potentially hazardous chemicals on the secured memory care unit. This affected 12 (#1, #3, #4, #5, #10, #11, #15, #16, #17, #21, #37, and #43) residents identified by the facility as being cognitively impaired, independently mobile, and residing on the memory care unit. In addition, the facility failed to implement fall interventions as care planned for one (#42) resident of three residents reviewed for falls. The facility census was 47. Findings include: 1. Observation on 03/28/22 at 8:50 A.M. of Resident #4's room, located on the secured memory care unit, revealed a full 16 fluid ounce (fl. oz.) bottle of dry mouth rinse with a warning label to keep out of reach of children, and a half-full 7.5 fl. oz. bottle of shampoo and body wash with a warning label to keep out of reach of children on the resident's bedside table. Observation on 03/28/22 at 9:00 A.M. of Resident #28's room, located on the secured memory care unit, revealed 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 and staff interview, the facility failed to have sufficient dietary staff to perform all dietary functions, including dish washing. This had the potential to affect 45 out of 47 residents who receive meals from the kitchen, the facility identified two (#197 and #198) residents who receive no nutrition from the kitchen. The facility census was 47. Findings include: Observation on 03/28/22 at 7:37 A.M. of the kitchen revealed Dietary Supervisor (DS) #516 and one aide preparing breakfast for the residents. Observation on 03/28/22 at 8:41 A.M. of the memory care unit dining room revealed residents eating breakfast. Breakfast was served in Styrofoam containers. Beverages, with the exception of coffee, was served in Styrofoam cups, and residents had plastic cutlery. Observation on 03/29/22 at 8:43 A.M. of the East Wing breakfast tray service revealed the meals were served in Styrofoam containers, beverages were served in Styrofoam cups, and plastic cutlery was provided to residents. Observation on 03/29/22 at 12:00 P.M. of the East Wing lunch tray service 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 review of the facility menu, review of facility documents, observations and resident and staff interview, the facility failed to follow established menus, failed to post menus, substitutions, and alternative menu selections, and failed to maintain a substitution log. This had the potential to affect 45 out of 47 residents who receive meal trays, the facility identified two residents (#197 and #198) residents who receive no nutrition from the kitchen. The facility census was 47. Findings include: 1. Interview on 03/28/22 at 11:32 A.M. of Dietary Supervisor (DS) #516 revealed a substitution was made for the lunch meal. Instead of the listed menu item of oven fried chicken, DS #516 stated she had leftover corned beef and decided to make [NAME] sandwiches and believed the residents would enjoy them. DS #516 stated substitutions were communicated to residents during Coffee Club, which was facilitated by the activities department, and she believed they met each morning. Interview on 03/29/22 at 9:50 A.M. 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, staff interview, and review of facility policy, the facility failed to serve meals at appropriate temperatures. This had the potential to affect 45 out of 47 residents who received meal trays, the facility identified two (#197 and #198) residents who did not receive nutrition from the kitchen. The facility census was 47. Findings include: Observation on 03/28/22 at 11:52 A.M. of the kitchen revealed Dietary Supervisor (DS) #516 and Dietary [NAME] (DC) #528 preparing and plating lunch meals into Styrofoam containers for delivery to the Homestead (secured memory care) unit of the facility. The meal consisted of [NAME] sandwiches, macaroni and cheese, and green beans. As each Styrofoam container was prepared, it was placed on a tray on an open, uninsulated meal cart. Pureed meals were prepared and plated into the Styrofoam containers by DS #516 while DC #528 prepared regular textured [NAME] sandwiches on the grill. At 12:23 P.M., the Homestead meal cart was ready for delivery to the unit. 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 of alternative menu options, resident and staff interview, and review of facility policy, the facility failed to offer residents preferred meal options. This had the potential to affect 45 out of 47 residents who received meal trays, the facility identified two (#197 and #198) residents who received no nutrition from the kitchen. The facility census was 47. Findings include: Interview on 03/28/22 at 2:10 P.M. with Resident #30 revealed the resident did not know she was having a sandwich for lunch and did not like her lunch meal. Resident #30 stated she was not provided with a menu and was unaware of what the lunch meal was. Interview on 03/29/22 at 7:59 A.M. of State Tested Nurse Aides (STNA) #557 and #558 revealed the facility staff did not ask residents about their menu selections. Both STNA's stated, under the previous ownership, residents completed a menu selection each day for their meal preferences, whether it was the main menu selection or an alternative, but that was no longer the practice at the facility. In addition, menus used to be posted 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 observation and staff interview, the facility failed to use appropriate hand hygiene when preparing meals. This had the potential to affect 45 out of 47 residents who receive meals from the kitchen, except for two (#197 and #198) residents, identified by the facility as receiving no food by mouth. The facility census was 47. Findings include: Observation on 03/28/22 at 11:52 A.M. of lunch preparation in the kitchen revealed Dietary Supervisor (DS) #516 preparing [NAME] sandwiches. DS #516, with the same gloved hands, touched her hairnet, picked up a can of non-stick spray, sprayed the grill, picked up a sealed package of Swiss cheese, picked up a knife and used it to open the pack of cheese, reached into the plastic bag of a loaf of bread and removed four slices of bread, picked up a brush and buttered the slices of bread, removed cheese slices from the package and placed on the bread, picked up the slices of bread with cheese and walked to the steam and picked up tongs to place corned beef on 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, family and staff interview, and review of facility policy, the facility failed to notify the physician when an ordered treatment could could not be provided. This affected one resident (#24) out of one resident reviewed for physician notification. The facility census was 47. Findings include: Review of the medical record for Resident #24 revealed an admission date of 07/03/21 and a readmission date of 11/11/21. Diagnoses included schizoaffective disorder, unspecified dementia, major depressive disorder, anxiety disorder, blindness right eye, and urinary tract infection (UTI). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was severely cognitively impaired and received intermittent catherization (cath). Review of the plan of care revealed Resident #24 had bladder incontinence. Interventions included monitor for signs and symptoms of UTI, including pain, burning, blood tinged urine, cloudiness, no output, and altered mental status.…

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, resident and family interviews and staff interview the facility failed to ensure resident equipment including, intravenous (IV) poles and wheelchairs, were in safe working order. This affected two (#45 and #24) residents, out of 28 residents reviewed for safe environment. The facility census was 47. Findings include: 1. Record review for Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses included osteomyelitis, chronic respiratory failure, infection in surgical wound, malnutrition, hernia, pressure ulcer of sacrum stage four, sepsis, and spinal stenosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition, was a one person physical assist with Activities of Daily Living (ADLs), had one unstageable pressure ulcer, one stage III pressure ulcer, and two venous/arterial ulcers. Review of Resident #45's physician orders dated 03/16/22 revealed the resident was to receive Cefepime,…

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 facility policy, the facility failed to provide discharge documentation to another facility upon discharge of a resident. This affected one resident (#47) of one reviewed for discharge. The facility census was 47. Findings include: Review of the medical record for Resident #47 revealed he was admitted on [DATE] and discharged to another facility on 01/14/22. Diagnoses included vascular dementia with behavioral disturbance, schizophrenia, and type II diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition. He required limited assistance of one person for bed mobility, supervision of one person for transfers and walking, and required extensive assistance of two people for toileting and hygiene. Review of a nursing progress note dated 01/13/22 revealed the receiving facility requested paperwork to be completed before Resident #47's transfer on 01/14/22. The medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide written transfer notification to residents transferred to the hospital. This affected two (#197 and #49) of three residents reviewed for transfer notices. The facility census was 47. Findings include: 1. Review of the medical record for Resident #197 revealed an admission date of 08/17/21 and a readmission date of 03/23/22. Diagnoses included dysphagia following cerebral infarction (stroke), schizoaffective disorder, hemiplegia and hemiparesis, heart disease, major depressive disorder, pleural effusion, and dementia. Additional review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #197 was severely cognitively impaired. Review of the census revealed Resident #197 was transferred to the hospital on [DATE] and on 03/18/22. Additional review of the medical record revealed no evidence written transfer notices were provided to the resident or her power of attorney (POA) for the transfers on 03/11/22…

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 interview, record review, staff interview, review of the admission agreement, and review of facility policy, the facility failed to provide written bed hold notices upon transfer from the facility. This affected three (#45, #49, and #197) of three residents reviewed for hospitalization. The facility census was 47. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Per the record the resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses for Resident #45 included osteomyelitis, chronic respiratory failure, infection in surgical wound, malnutrition, hernia, pressure ulcer of sacrum stage four, sepsis, and spinal stenosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition, was a one person physical assist with Activities of Daily Living (ADLs), had one unstageable pressure ulcer, one stage III pressure ulcer, and two…

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 facility policy, the facility failed to develop comprehensive care plans for ostomy wound care, pressure ulcers, and oxygen. This affected two residents (#25 and #45) out of 28 residents reviewed for care plans. The facility census was 47. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #45 included osteomyelitis, chronic respiratory failure, infection in surgical wound, malnutrition, hernia, pressure ulcer of sacrum stage four, sepsis, and spinal stenosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition, was a one person physical assist with Activities of Daily Living (ADLs), had one unstageable pressure ulcer, one stage III pressure ulcer, an ostomy, and two venous/arterial ulcers. Review of Resident #45's admission assessment dated [DATE] revealed the resident had a pressure ulcer…

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 have complete a discharge summary upon discharge of a resident. This affected one resident (#47) out of one resident reviewed for discharge. The facility census was 47. Review of the medical record for Resident #47 revealed he was admitted on [DATE] and discharged to another facility on 01/14/22. Diagnoses included vascular dementia with behavioral disturbance, schizophrenia, and type 2 diabetes mellitus. Review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #47 had impaired cognition. He required limited assistance of one person for bed mobility, supervision of one person for transfers and walking, and required extensive assistance of two people for toileting and hygiene. A review of the medical record for Resident #42 revealed no discharge summary. Interview on 03/31/22 at 10:29 A.M. with the Director of Nursing confirmed there was no discharge summary in Resident #47's record. 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 and staff interviews, medical record review, review of the facility's shower schedule, and review of policy for personal care, the facility failed to provide showers as scheduled for one resident (Resident #27) of one resident reviewed for activities of daily living (ADL). The facility census was 47. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted [DATE] and with diagnoses including systemic lupus, generalized, bipolar disorder, peripheral vascular disease, chronic kidney disease, neuromuscular dysfunction of bladder, obesity, and major depressive disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #27 dated 02/04/22, revealed the resident was cognitively intact and did not reject care. The assessment further revealed Resident #27 required extensive assistance with hygiene and was dependent for bathing. Review of the care plan for Resident #27 revealed an ADL self-care performance deficit related to limited…

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, staff interview, and review of facility policy, the facility failed to complete wound assessments for one (Resident #45) and failed to provide pressure wound treatments for one (Resident #18) out of three residents reviewed for wound care. The facility census was 47. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #45 included osteomyelitis, chronic respiratory failure, infection in surgical wound, malnutrition, hernia, pressure ulcer of sacrum stage four, sepsis, and spinal stenosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition, was a one person physical assist with Activities of Daily Living (ADLs), had one unstageable pressure ulcer, one stage III pressure ulcer, and two venous/arterial ulcers. Review of Resident #45's admission assessment dated [DATE] revealed the resident had a pressure ulcer on left heel, pressure ulcer 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.

Based on medical record review, review of a dietary meal ticket, staff interview, and review of facility policy, the facility failed to ensure residents were provided with physician ordered diets. This affected one (#23) of one residents reviewed for nutrition. The facility census was 47. Findings include: Review of the medical record for Resident #23 revealed an admission date of 06/10/20 and a readmission date of 10/06/20. Diagnoses included end stage renal disease, hypertension, obstructive and reflux uropathy, dependence on renal dialysis, presence of urogenital implants, malignant neoplasm of prostate, and benign prostatic hyperplasia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/13/22, revealed Resident #23 was cognitively intact and was on dialysis. Review of the plan of care, dated 10/19/20, revealed Resident #23 had a nutritional problem or potential nutritional problem related to dependence on hemodialysis, history of malnutrition, acute kidney failure, anemia, and therapeutic diet use. Interventions included serve diet as ordered. Review of current…

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 timely review pharmacy recommendations. This affected three (#15, #24, and #28) of five residents reviewed for unnecessary medications. The census was 47. Findings include: 1. Review of the medical record for Resident #15 revealed the resident was admitted [DATE] and had diagnoses that included Alzheimer's disease, adjustment disorder with depressed mood, insomnia, generalized anxiety disorder, delusional disorders, cognitive communication deficit, and sexual disorders. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #15 revealed the resident had severe cognitive impairment. The assessment indicated Resident #15 exhibited no behaviors. Review of physician orders for Resident #15 revealed they included an order dated 02/25/21, for Cimetidine (an antihistamine and antiacid) 400 milligrams twice daily for sexual behaviors. Review of monthly pharmacy reviews for Resident #15 revealed that on 02/10/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview and review of the facility policy, the facility failed to accurately document the administration of oxygen. This affected one (#25) of one reviewed for oxygen use. The facility census was 47. Findings include: Review of the medical record for Resident #25 revealed an admission date of 08/18/21. Diagnoses included Alzheimer's disease, dementia, acute respiratory failure with hypoxia, and type 2 diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, and hygiene, and extensive assistance of one person for transfer and toileting. Review of the physician orders for Resident #25 revealed an order dated 12/06/21 for oxygen at two to four liters per minute via nasal cannula every shift. Review of the March 2022 Medication Administration Record (MAR) for Resident #25 revealed staff documented twice daily…

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.