Manor At Perrysburg

Based on observation, staff interview, record review and policy review, the facility failed to ensure proper equipment for residents with a tracheostomy were available at bedside. This affected one (#7) of one resident reviewed for a tracheostomy. Resident #7 was the only resident in the facility with a tracheostomy. The facility census was 96.Findings Include:Review of the medical record for Resident #7 revealed an admission date of 03/15/25 with respiratory failure and tracheostomy status.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/25, revealed Resident #7 had intact cognition and had a tracheostomy.Review of the care plan initiated 03/15/25 for Resident #7 revealed to keep an extra tracheostomy tube and obturator (a curved rod designed to help the tracheostomy tube fit into the trachea) at bedside.Review of the current physician order initiated 03/18/25 revealed Resident #7 had an order to change tracheostomy tube with size 5.5 and style 41c65 Name of Tracheostomy Shiley every day shift every 90 day(s) for tracheostomy maintenance with Pulmonologist…

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 ensure pre and post dialysis assessments were completed. This affected one (#54) of one resident reviewed for dialysis. The facility census was 96.Findings include:Review of the medical record for Resident #54 revealed an admission date of 07/05/25 with diagnoses including but not limited to Alzheimer's disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder depressive type, end stage renal disease, and vascular dementia.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #54 received dialysis.Review of current physician orders revealed the resident had dialysis on Monday, Wednesday, and Friday.Further review of the electronic medical records revealed no dialysis assessments.Interview on 08/20/25 at 11:26 A.M. with Regional Clinical Nurse (RCN #550) revealed the facility did not do the post dialysis assessments when the residents return from dialysis. RCN…

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, physician interview, staff interview, and review of Medscape website the facility failed to ensure residents were not given unnecessary medications. This affected one (#10) of six residents reviewed for unnecessary medications. The facility census was 96.Findings include:Review of medical record for Resident #10 revealed an admission date of 09/08/20 with diagnoses including Alzheimer's disease with late onset, epilepsy, major depressive disorder severe with psychotic features, dementia with psychotic disturbance, delusional disorders, generalized anxiety disorder, other schizoaffective disorders, and subdural hematoma.Review of minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment.Review of current physician orders revealed Lovenox (blood thinner) injection prefilled syringe kit 40 milligrams (mg)/0.4 milliters (ml) daily for prevention of blood clot request clarification with Neurosurgery follow up on 06/23/25 (started on 06/11/25 and continued 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.

Based on record review, staff interview and policy review, the facility failed to ensure nutrition assessments were completed timely. This affected one (#50) of five residents reviewed for nutrition. The facility census was 96. Findings Include:Review of the medical record for Resident #50 revealed an admission date of 09/27/24 with diagnoses of Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive. Review of the significant change comprehensive minimum data set (MDS) assessment, dated 07/21/25, revealed Resident #50 was rarely/never understood and was dependent for all activities of daily life. Review of the physician order dated 07/15/25 revealed Resident #50 was admitted to hospice. Review of the medical record revealed a quarterly nutrition progress note was completed on 04/29/25. Further review revealed no more recent quarterly or annual nutrition assessment was completed. Additionally, no comprehensive nutrition assessment was completed after Resident #50 had a significant change and was admitted to hospice on 07/15/25.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.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure enhanced barrier precautions were practiced during tracheostomy care. This affected one resident (#7) observed for tracheostomy care. The facility identified only one resident with a tracheostomy in the facility. The facility census was 96. Findings Include:Review of the medical record for Resident #7 revealed an admission date of 03/15/25 with respiratory failure, tracheostomy status, and history of methicillin resistant staphylococcus aureus (MRSA) (a drug resistant bacteria) infection. Review of the current physician orders for August 2025 for Resident #7 revealed she did not have an order for Enhanced Barrier Precautions (EBP) (precautions used to prevent infections for residents with areas of enhanced portals of entry such as tracheostomy or wounds). Review of the care plan initiated in March 2025 for Resident #7 revealed she was care planned for EBP due to have a tracheostomy and gastric feeding tube with a goal of understanding that staff will wear personal protective equipment…

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 facility electronic medical record (EMR), review of external provider documents, staff interview, interview with external provider staff, and policy review, the facility failed to ensure a resident timely received medications upon discharge. Additionally, the facility failed to ensure timely notification of Social Security (SS) of discharge. This affected one (#110) of three residents (#110, #112, and #114) reviewed for discharge rights. Findings include: 1. Review of the EMR for Resident #110 revealed an admission date of 07/25/24 and a discharge date of 03/12/25 with diagnoses including frontotemporal neurocognitive disorder, type two diabetes mellitus (DM2), Vitamin D deficiency, hyperlipidemia, frontal lobe and executive dysfunction, retention of urine, dementia in other diseases classified elsewhere, gastroesophageal reflux disease (GERD), constipation, atrial fibrillation (a. fib), hereditary and idiopathic neuropathy, hypertension (HTN), and multiple myeloma not having received remission. Review of the most recent State Minimum Data Set (MDS) Assessment 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, review of the facility policy, and staff interview, the facility failed to ensure medications were administered via feeding tube per physician orders. This affected one resident (#15) out of 6 residents reviewed for medications. The census was 95. Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include sick sinus syndrome, traumatic brain injury, dysphagia, and dementia. Review of Resident #15's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving nutrition through a feeding tube. Review of Resident #15's care plans dated 02/19/25 revealed a focus for alteration in gastro-intestinal status related to Percutaneous Endoscopic Gastronomy (PEG) tube for tube feeding and nothing per mouth due to dysphagia. Interventions include administering medications per order. Further review of the care plans dated 03/16/25 revealed a focus 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, record review, review of the facility policies, and staff interview, the facility failed to ensure all nursing care was provided in accordance with standards and practices. This affected three residents (#15, #16, and #18) of three residents observed for medication administration. The current census was 95. Findings include: 1. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include sick sinus syndrome, traumatic brain injury, dysphagia, and dementia. Review of Resident #15's Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving nutrition through a feeding tube. Review of Resident #15's care plans dated 02/19/25 revealed a focus for alteration in gastro-intestinal status related to Percutaneous Endoscopic Gastronomy (PEG) tube for tube feeding and nothing per mouth due to dysphagia. Interventions include administering medications per order. Further…

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, review of the facility policies, staff interview, and review of medical records, the facility failed to ensure a medication error rate lower than 5%. The error rate on 03/26/24 was 19%, this affected three residents (#15, #17, and #18) of three residents observed for medication administration. The current census is 95. Findings include: Observation on 03/26/25 from 9:15 A.M. to 10:01 A.M. of Licensed Practical Nurse (LPN) #100 administering medications to the residents on the B-hall revealed there to be 11 medication errors noted during 3 medication administrations for Resident #15, Resident #17, and Resident #18. LPN #100 was observed administering 57 medications to four residents during the observation. 1. Review of Resident #15's care plans dated 02/19/25 revealed a focus for alteration in gastro-intestinal status related to Percutaneous Endoscopic Gastronomy tube, (PEG) for tube feeding and nothing per mouth due to dysphagia. Interventions include administering medications per order.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of the facility policies, and staff interview, the facility staff failed to properly administer insulin medications per the manufacturer's guidelines. This affected one resident (#18) out of five residents observed receiving medications. The current census was 95. Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include diabetes type two, chronic obstructive pulmonary disease, and obesity. Review of Resident #18's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition and was receiving insulin injections. Review of Resident #18's care plans dated 09/21/23 revealed a focus for diabetes mellitus. Interventions include checking blood glucose per physician order and to administer medications per order. Review of Resident #18's physician ordered medications dating from 09/30/23 to 03/25/25 revealed the resident was ordered to receive Amiodarone 200 mg,…

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 medical record, staff interview, and review of facility policy, the facility failed to ensure physician ordered medications were available for administration. This affected two residents (#26 and #80) of five (#26, #71, #80, #89, and #93) residents reviewed for accurate medical records. The Facility census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/02/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type II diabetes mellitus, vascular dementia, hyperlipidemia, hypertension (HTN), symptomatic epilepsy and epileptic syndrome, bipolar disorder, gastroesophageal reflux disease (GERD), and aphasia following cerebral infarction. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #26 was severely cognitively impaired. Review of the current physician orders for Resident #26 revealed an order dated 09/12/24 for Famotidine (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 review of facility medical record, review, staff interview, and review of facility policy, the facility failed to ensure that residents were free of significant mediation errors. This affected three residents (#26, #89, and #93) of five residents (#26, #71, #80, #89, and #93) reviewed for accurate medical records. The Facility census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/02/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type II diabetes mellitus, vascular dementia, hyperlipidemia, hypertension (HTN), symptomatic epilepsy and epileptic syndrome, bipolar disorder, gastroesophageal reflux disease (GERD), and aphasia following cerebral infarction. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #26 was severely cognitively impaired. Further review of the current physician orders for Resident #26 revealed a physician order…

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 gloves were worn while administering subcutaneous insulin. This affected one resident (#71) of five (#26, #71, #80, #89, and #93) reviewed for medication administration. The facility identified 24 residents (#3, #4, #7, #8, #9, #10, #17, #26, #28, #29, #32, #39, #42, #50, #61, #65, #67, #69, #70, #71, #73, #79, #89, and #93) who were prescribed insulin. The facility census was 92. Findings include: Review of the medical record for Resident #71 revealed an admission date of 02/18/23 with diagnoses of hemiplegia and hemiparesis, and type two diabetes mellitus, type II. Review of the current physician orders for Resident #71 revealed an order, dated 05/03/22, for 16 units of Lantus SoloStar Solution Pen-injector 100 unit per milliliter (ml) to be administered subcutaneously (injected under the skin) (SQ) one time a day for diabetes mellitus, type II. Observation of medication administration to Resident #71 on 01/14/25 at 7:40 A.M. revealed Registered Nurse (RN)…

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, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders. Additionally, the facility failed to maintain controlled substance drug records. This affected four (#118. #24, #117, #84) of seven residents reviewed for medication administration. The facility census was 99. Findings include 1. Review of the medical record for Resident #118 revealed an admission date of 03/30/23 and a discharge date of 06/26/24. Diagnoses included Alzheimer's disease with late onset, chronic obstructive pulmonary disease, dementia, chronic kidney disease, hypertension, and chronic diastolic heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the physician orders dated 06/18/24 revealed the resident was ordered Ceftriaxone sodium injection solution reconstituted one gram, inject one gram intramuscularly one time only for infection for one 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 review of the medical record, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was timely completed. This affected one (#100) of three residents reviewed for care planning. The facility census was 99. Findings include Review of the medical record for Resident #100 revealed an admission date of 09/30/24. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, vascular dementia, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was always incontinent of bowel and bladder. Review of the comprehensive care plan dated 10/01/24 and last revised on 10/12/24 revealed there was no care plan in place for incontinence care. Review of the continence task documentation from 09/30/24 through 10/22/24 revealed the resident was always incontinent of bowel and bladder. Interview on 10/22/24 at 7:23 A.M., Licensed Practical Nurse (LPN) #423 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.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents were provided with assistive devices as ordered/care planned. This affected one (Resident #27) out of three residents reviewed for assistance with drinking. The facility census was 104. Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/22/23 with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, type two diabetes, cognitive communication deficit, vascular dementia, disorientation, delirium, essential tremor, and hypertension. Review of Resident #27's Medicare 5-day Minimum Data Set assessment, dated 12/28/23, revealed Resident #27 had a brief interview of mental status score of zero which indicated severe cognitive impairment. Resident #27 required supervision/touching to moderate assistance for activities of daily living. Resident #27 was dependent on staff for transfers. Review of the Nursing Interdisciplinary Meeting Note, dated 03/07/24, revealed nursing…

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

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 wound treatments were applied in accordance with physician orders and failed to ensure wound measurements were consistently and accurately maintained in the medical record. This affected one (#3) of three residents reviewed for pressure ulcer wound management and care. Facility census was 98. Findings include: Resident #3 admitted to the facility on [DATE] with the diagnosis including, heart failure, chronic vascular disorder of intestine, hypotension, malignant neoplasm of appendix, benign prostatic hyperplasia, obstructive and reflux uropathy, rhabdomyolysis, anxiety disorder, major depression, chronic embolism and thrombosis, lymphedema, stage 4 pressure ulcer to sacral region, unstageable pressure ulcer to right heel, urinary tract infection, and asthma. According to the most current minimum data set assessment dated [DATE] assessed Resident #3 with intact cognition, dependent on staff…

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 facility policy, the facility failed to ensure proper hand hygiene was practiced during meal services. This directly affected five (#30, #93, #94, #100, and #307) residents and had the potential to affect all residents in the facility except one resident (#38) the facility stated did not receive food from the kitchen. The facility census was 99. Findings include: Observations on 11/28/23 beginning at 11:57 A.M. revealed [NAME] #503 wearing gloves and plating food for the noon meal. [NAME] #503 opened a drawer searching for a serving utensil, used a ladle to pour a bowl of soup, opened a plastic bag of hamburger buns, picked up a hamburger bun with his gloved hands, opened it on the plate and used a utensil to scoop mechanical soft bologna onto the sandwich then used the same gloved hand to close the sandwich. [NAME] #503 stated the meal he just plated was for Resident #30. [NAME] #503 continued to touch serving utensils for bologna slices, ground bologna, pureed bologna, wax beans, and soup with his gloved hands, 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 observation, resident interview, staff interview, and review of the manufacturer specifications, the facility failed to ensure residents were provided beds of the appropriate length. This affected one (Resident #101) of three reviewed for accommodation of needs. The facility census was 99. Findings Include: Review of Resident #101's medical record revealed an admission date of 10/18/23. Diagnoses included type II diabetes, hypertension, muscle weakness and encounter for orthopedic after care. Review of Resident #101's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #101 was cognitively intact. Resident #101 was independent with eating and oral care. Resident #101 required assistance from staff with dressing and mobility. Resident #101 was dependent on staff for toileting and bathing. Resident #101 displayed no behaviors during the review period. Review of Resident #101's care plan revised 11/11/23 revealed supports and…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were consistent within the medical record. This affected two (Residents #74 and #258) of two residents reviewed for advanced directives. The facility census was 99. Findings include: 1. Review of Resident #74's medical record revealed an admission date of 11/04/22. Diagnoses include frontal lobe and executive function deficit following cerebral infarction, morbid obesity, type 2 diabetes mellitus, psychotic disorder with hallucinations due to known physiological condition, chronic diastolic (congestive) heart failure, cardiomegaly, cerebral infarction, vascular dementia and metabolic encephalopathy. Review of Resident #74's paper medical record revealed a Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest) form dated 11/20/23 revealing the resident's advanced directive was DNRCC - Arrest. Review of current physician order dated 08/19/23, located in the electronic medical record (EMR), revealed Resident #74's advanced directive was Do Not…

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 the physician when a wound treatment was not completed. This affected one (Resident #257) of two residents reviewed for wounds. Additionally, the facility failed to notify the physician regarding ongoing complaints of elevated pain. This affected one (Resident #101) of one resident reviewed for pain. The facility census was 99. Findings include: 1. Review of the medical record for Resident #257 revealed an admission date of 11/23/23 with diagnoses of infection and inflammatory reaction due to internal joint prosthesis. Review of the Nursing Admission/readmission Screener dated 11/23/23 revealed Resident #257 was alert and oriented to person, place, time, and situation. Further review revealed Resident #257 was admitted with a left hip open wound with a wet to dry dressing and expectation a negative pressure wound therapy (NPWT) (a method of drawing out fluid and infection from a wound to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of bathing documentation, staff interview, and policy review, the facility failed to ensure resident showers were completed as scheduled. This affected one (Resident #64) of two residents reviewed for choices. The facility census was 99. Findings include Review of the medical record revealed Resident #64 had an admission date of 11/23/22. Diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care last revised 12/03/22 revealed the resident required staff participation with bathing. Review of the shower schedule revealed Resident #64 was scheduled for showers on Tuesdays and Fridays on day shift. Review of shower documentation for the last 30 days revealed no documentation Resident #64 received showers on 11/03/23, 11/14/23, and 11/24/23. Review of the nurse's notes dated 11/01/23 through 11/29/23…

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

Based on record review, resident interview, staff interview, and review of the facility policy, the facility failed to complete an initial wound assessment and failed to complete wound treatments as ordered for one (Resident #257) of two residents reviewed for wound care. The facility census was 99. Findings include: Review of the medical record for Resident #257 revealed an admission date of 11/23/23 with diagnoses of infection and inflammatory reaction due to internal joint prosthesis. Review of the Nursing Admission/readmission Screener dated 11/23/23 revealed Resident #257 was alert and oriented to person, place, time, and situation. Further review revealed Resident #257 was admitted with a left hip open wound with a wet to dry dressing and expectation a Negative Pressure Wound Therapy (NPWT) (a method of drawing out fluid and infection from a wound to help it heal) would be applied after admission. Review of a physician order dated 11/23/23 revealed Resident #257 should receive NPWT applied the left hip every Monday, Wednesday, and Friday at 125 millimeters of mercury (mmHg),…

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 observations, staff interview, and facility policy review, the facility failed to appropriately check the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administering medications. This affected one (Resident #357) of three residents reviewed for PEG tube medication administration. The facility census was 99. Findings include: Review of the medical record for Resident #357 revealed an admission date of 11/16/23 with diagnoses of cerebral vascular accident (CVA) (stroke) and gastrostomy tube. Review of the five-day Minimum Data Set (MDS) dated [DATE] for Resident #357 revealed the resident was cognitively impaired. Review of Resident #357's physician orders for November 2023 revealed medications were to be administered via PEG tube, regular mechanical soft diet with nectar thickened liquids, and tropical liquid supplement to be administered via PEG tube if the resident ate less than 75% of a meal. Observation on 11/28/23 at 8:17 A.M. of Registered Nurse (RN) #492 checking for PEG…

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 interview, staff interview, and review of the facility policy, the facility failed ensure pain interventions were in place for a resident. This affected one (Resident #101) of one resident reviewed for pain management. The facility census was 99. Findings include: Review of Resident #101's medical record revealed an admission date of 10/18/23. Diagnoses included type 2 diabetes mellitus, osteomyelitis, essential hypertension, anemia, essential hypertension, cauda equina syndrome, muscle weakness, insomnia and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified Resident #101 was cognitively intact, was alert and oriented and was able to make his needs known. Resident #101 received scheduled and as needed pain medications. Further review revealed the resident did not receive non-medication interventions for pain. Review of the care plan for Resident #101 dated 10/19/23 revealed the resident had…

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 controlled pain medication administration was accurately documented throughout the resident's medical record. This affected one (#101) of one resident reviewed for pain management. The facility census was 99. Findings include: Review of Resident #101's medical record revealed an admission date of 10/18/23. Diagnoses included type II diabetes mellitus, osteomyelitis (infection of the bone), hypertension, anemia, cauda equina syndrome (compressed nerve roots in the lumbar spine), muscle weakness, insomnia and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was cognitively intact. Review of Resident #101's Medication Administration Record (MAR) revealed the resident had orders for oxycodone HCI oral tablet, five milligrams (mg), one tablet every four hours as needed for moderate pain and oxycodone HCI oral tablet, five mg, 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 observation, staff interview and policy review, the facility failed to wear appropriate Personal Protective Equipment (PPE) while providing direct care to a resident on Enhanced Barrier Precautions (EBP). This affected one (#357) of four residents reviewed for Transmission-Based Precautions (TBP). The facility census was 99. Findings include: Review of the medical record for Resident #357 revealed an admission date of 11/16/23 with diagnoses including Cerebral Vascular Accident (CVA - stroke) and gastrostomy tube. Review of Resident #357's current physician orders revealed the resident's medications were to be administered via Percutaneous Endoscopic Gastrostomy (PEG - tube feeding) tube, was on a regular mechanical soft diet with nectar thickened liquids, and received tropical liquid supplement, to be administered via PEG tube if the resident eats less than 75% of a meal. Review of the five-day Minimum Data Set (MDS) dated [DATE] for Resident #357 revealed the resident was cognitively impaired. 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.

Based on medical record review, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy, the facility failed to ensure pneumococcal vaccines were administered per CDC guidelines. This affected three (#11, #62, #64) of five residents reviewed for pneumococcal vaccinations. The facility census was 99. Findings include 1. Review of the medical record for Resident #11 revealed an admission date 03/23/21. Diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic kidney disease. Review of the immunization records for Resident #11 revealed the resident last received a pneumococcal polysaccharide vaccine (PPSV23) on 01/05/22. Review of CDC recommendations for pneumococcal vaccine timing for adults, dated 02/16/22, revealed based on the resident's age and date of last pneumococcal immunization the resident should have been offered one dose of the pneumococcal 15-valent conjugate vaccine (PCV 15) or PCV20 one year after the…

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

Based on observation and staff interview, the facility failed to ensure a homelike environment when residents were provided a meal in the dining room on a meal tray. This affected 13 (#18, #19, #34, #38, #53, #54, #56, #61, #64 #89, #91, #92, and #96) of 13 residents observed in the dementia unit. The facility census was 100. Findings include: Observation on 06/07/21 at 12:30 P.M., revealed Resident #18, #19, #34, #38, #53, #54, #56, #61, #64, #89, #91, #92, and #96, in the dining room received their lunch meal on a tray and the tray was not removed while the resident ate. Interview on 06/07/21 at 12:51 P.M., with State Testing Nursing Assistant (STNA) #213 verified some of the residents in the dining room received their lunch meal on a tray and the tray remained in place while the resident ate. STNA #213 stated there was no specific reason this occurred.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of precautionary label and review of facility policies, the facility failed to ensure fall interventions were appropriately implemented as care planned and failed to ensure medications and laundry detergent were maintained in a safe manner on the locked dementia unit. This deficient practice affected one (#204) resident reviewed for fall interventions and had the potential to affect ten (#16, #17, #18, #19, #26, #34, #53, #61, #91, and #93) residents the facility identified as independently mobile and cognitively impaired on the locked dementia unit. The facility census was 100. Findings include: 1. Review of Resident #204's medical record revealed an original admission date of 05/12/21 and a most recent admission date of 05/25/21. Diagnoses included: cerebral infarction, diabetes mellitus type II, muscle weakness, metabolic encephalopathy, hyperlipidemia, and unsteadiness on feet. Review of an admission Minimum Data Set (MDS) assessment dated…

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

Based on observation, review of medical record, staff interview and review of facility policy, the facility failed to treat residents with dignity by hanging a sign with resident care needs above the resident's bed. This affected one (#100) of two residents reviewed for dignity. The facility census was 100. Findings include: Review of Resident #100's medical record revealed an admission date of 11/08/19 and a readmission date of 06/02/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; schizoaffective disorder, unspecified; gastro-esophageal reflux disease (GERD) without esophagitis; and essential (primary) hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/06/21, revealed Resident #100 was severely cognitively impaired and required extensive one person physical assistance with eating. Review of the care plan revealed Resident #100 had a self-care deficit and impaired mobility related to right sided weakness post cardiovascular accident (CVA). Interventions included eating assistance required,…

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 medical record review, the facility failed to ensure a baseline or comprehensive care plan was developed within 48 hours of admission for a resident admitted with a urinary catheter. This affected one (#208) of one residents reviewed with urinary catheters. The facility identified eight residents with urinary catheters. The census was 100. Findings include: Review of Resident #208's medical record revealed an admission date of 06/04/21. Diagnoses included encephalopathy, unspecified dementia with behavioral disturbances, hyperlipidemia, chlamydial pneumonia, and benign prostatic hyperplasia. Review of an admission nursing assessment dated [DATE] revealed Resident #208 was oriented to person only and was admitted to the facility with an indwelling urinary catheter. Review of a baseline care plan initiated on 06/04/21 and completed on 06/06/21, revealed no care plan was developed for Resident #208's urinary catheter care. Observation on 06/07/21 at 1:59 P.M. and 5:30…

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, resident and staff interviews, and review of facility policy, the facility failed to ensure resident participation in care conferences. This affected one (#5) of two residents reviewed for care conference participation. The facility census was 100. Findings include: Review of Resident #5's medical record revealed an admission date of 01/21/21. Diagnoses included chronic respiratory failure with hypoxia; unspecified atrial fibrillation; chronic obstructive pulmonary disease (COPD) unspecified; and type II diabetes mellitus without complications. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/14/21, revealed Resident #5 was cognitively intact. Review of a case management progress note dated 02/04/21 revealed a call was placed to Resident #5's daughter to schedule a care conference and was awaiting a return call. The medical record was silent for communication with the Resident regarding her care conference meetings or documentation of a care conference meeting until 04/14/21. Interview on 06/08/21 at 2:26 P.M., with the MDS Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, the facility failed to provide ongoing assistance with positioning in bed as indicated in the nursing plan of care. This deficient practice affected one (#11) of three residents reviewed for positioning. The facility census was 100. Findings include: Review of Resident #11's medical record revealed an admission date of 08/06/20, with diagnoses including: anemia, asthma, obstructive and reflux uropathy, chronic kidney disease, acute kidney failure, benign prostatic hyperplasia, acute embolism and thrombosis of lower bilateral extremities, polyneuropathy, malignant neoplasm of appendix, history of pressure ulcer to right heel, pressure ulcer to sacral region, hydronephrosis, hypotension, chronic vascular disorder of intestines, major depression, anxiety, and chronic congestive heart failure. Review of the most current minimum data set assessment dated [DATE] identified the resident as alert, able to make needs known, dependent on staff for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and and staff interviews, the facility failed to provide ongoing restorative nursing services in accordance with physical therapy recommendations. This deficient practice affected one (#11) of 24 residents reviewed for range of motion and treatment. The facility census was 100. Findings include: Review of Resident #11's medical record revealed an admission date of 08/06/20, with diagnoses including: anemia, asthma, obstructive and reflux uropathy, chronic kidney disease, acute kidney failure, benign prostatic hyperplasia, acute embolism and thrombosis of lower bilateral extremities, polyneuropathy, malignant neoplasm of appendix, history of pressure ulcer to right heel, pressure ulcer to sacral region, hydronephrosis, hypotension, chronic vascular disorder of intestines, major depression, anxiety, and chronic congestive heart failure. Review of the most current minimum data set assessment dated [DATE] identified the resident as alert, able to make needs known, dependent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure a resident admitted with a urinary catheter had a physician order for use and failed to ensure care was provided for the urinary catheter. This affected one (#208) of one residents reviewed with urinary catheters. The facility identified eight residents with urinary catheters. The census was 100. Findings include: Review of Resident #208's medical record revealed an admission date of 06/04/21. Diagnoses included encephalopathy, unspecified dementia with behavioral disturbances, hyperlipidemia, chlamydial pneumonia, and benign prostatic hyperplasia. Review of a hospital after care summary revealed Resident #208 was treated in the hospital between 05/25/21 and 06/04/21 and revealed Resident #208 had a urinary catheter inserted on 06/02/21 for acute urinary retention and obstruction. Review of an admission nursing assessment dated [DATE] revealed Resident #208 was oriented to person only 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.