Pickerington Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to develop and implement a comprehensive care plan addressing the use of hand splints for a resident with contractures. This deficient practice affected one resident (Resident #5) out of three residents reviewed for care planning. The facility census was 71.Findings Include: Review of Resident #5's medical record revealed admission date 03/03/23 with diagnoses including but not limited to congestive heart failure (CHF), anoxic brain damage, respiratory failure, ventilator dependent, high blood pressure and anxiety. Review of Resident #5's quarterly [NAME] Data Set (MDS) dated [DATE] revealed Resident #5 had severe impaired cognition and was dependent on staff for all care. Review of Resident #5's physician orders revealed an order dated 06/17/25 for staff to don bilateral resting hand splints up to 6 hours daily as tolerated and to check skin integrity and circulation every shift. Review of Resident #5's Treatment…

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, resident and staff interviews and record review, facility failed to revise a dental care plan for two Residents (#32 and #60) and a vision care plan for one Resident (#82). This affected three residents (#32, #60 and #82) out of 25 residents in the survey sample. Facility census was 71. Findings include 1. Review of the medical record for Resident #32 revealed an admission date of 02/03/25. Diagnoses included cardiac arrest, open wound to the buttock, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, retention urine. Review of the plan of care dated 02/06/25 revealed the resident had an impaired dental status as evidenced by dentures. It noted the resident lost some/all natural teeth with interventions to arrange for dental consults and follow up visits by dentistry as needed. Review of dental visit note dated 03/28/25 revealed the resident wore dentures. Review of progress note dated 07/15/25 revealed the resident returned from a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and facility policy review, the facility failed to ensure nail care was provided for dependent care residents. This deficient practice affected three residents (Residents #26, #77, and #80) out of seven residents reviewed for activities of daily living (ADL) care for dependent residents. The facility's census was 71.Findings Include: 1. Review of Resident #26's medical record revealed an admission date of 05/22/23 with the diagnoses including, but not limited to, respiratory failure, epilepsy, anxiety, and schizoaffective disorder. Review of Resident #26's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #26 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 10 out of possible 15 and was dependent on staff for completion of bathing and personal hygiene tasks. Review of Resident #26's ADL care plan dated 06/07/23 revealed Resident #26 required staff assistance with personal hygiene tasks. 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, observation and staff interview, the facility failed to ensure ongoing resident centered activities program that incorporated the resident's interests, hobbies and cultural preferences. This affected one (Resident #87) of four residents observed for activities. The census was 71.Findings include: Review of Resident #87's medical record revealed he was admitted on [DATE]. Diagnoses included non traumatic intracerebral hemorrhage, acute respiratory failure, seizures, encephalopathy, dysphagia, tracheostomy and gastrostomy. Review of the quarterly minimum data set assessment dated [DATE] revealed he was cognitively impaired, he was dependent upon staff for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. He also had an indwelling urinary catheter and was always incontinent of bowel. Review of the activity assessment dated [DATE] revealed he enjoyed listening to music, staff would offer one to one visits for stimulation and staff would…

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 interviews, and facility policy review, the facility failed to prevent a delay in treatment for a resident requiring antibiotic use (Resident #1). This affected one resident (Residents #1) out of four residents reviewed for quality of care. The facility census was 71.Findings Include: Review of Resident #1's medical record revealed admission date of 08/14/25 with diagnoses including but not limited to pleural effusion, chronic obstructive pulmonary disease (COPD), pneumonia, depression, high blood pressure, and anxiety. Review of Resident #1's progress notes revealed on 09/10/25 at 9:33 P.M. Resident #1 showed the nurse a medication cup with brown/tan colored sputum in it. Notification was made to MedOne and an order was received for a chest X-ray and to complete a SARS-CoV-2 (COVID-19) test, with the COVID-19 test results being negative at 10:17 P.M. Review of the chest X-ray results dated 09/11/25 at 10:30 A.M. revealed Resident #1 had bilateral lower lobe atelectasis (complete or partial collapse of a lung or a section of lung) with possible right…

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, record review, and review of facility policy, the facility failed to ensure timely follow up for ophthalmology services for one Resident (#82) of one reviewed for ophthalmology services. Facility census was 71. Findings include:Review of the medical record for Resident #82 revealed an admission date of 08/24/20. Diagnoses included acute cystitis, sepsis, diabetes type two, cognitive communication deficit, dysphagia, and muscle weakness. Review of the plan of care dated 04/21/22 revealed the resident was at risk for visual decline and wore glasses. Interventions included encourage the resident to wear glasses, keep call light in reach, and keep glasses in a safe space. The care plan did not include any mention of changes in vision, increased blurring of vision or recommendations for cataract surgery. Review of the eye exam dated 04/17/25 revealed cataract surgery was recommended for Resident #82 with a follow up in four to five months. It stated to continue wearing glasses…

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, record review, and review of facility policy, the facility failed to ensure appropriate care and services for Resident #32 who utilized a Foley catheter. This affected one resident (#32) of one reviewed for catheters. Facility census was 71. Findings include Review of the medical record for Resident #32 revealed an admission date of 02/03/25. Diagnoses included cardiac arrest, open wound to the buttock, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, retention urine. Review of the plan of care dated 02/06/25 revealed the resident had potential for complications related to use of the Foley (indwelling) catheter. The catheter was indicated due to obstructive uropathy. Interventions included change Foley catheter as needed for plugging or displacement, notify the physician if there was a change in urine color consistency or output, obtain output each shift and total for 24-hour period, and provide Foley care per facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview and review of facility policy the facility failed to ensure dietary adaptive equipment was provided for a dependent resident. This deficient practice affected one resident (Resident #20) out of two residents reviewed for adaptive equipment use. The facility census was 71.Findings Include:Review of Resident #20's medical record revealed admission date 11/14/22 with diagnoses including but not limited to high blood pressure, depression, dementia, contractures, and dysphagia.Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #20 had impaired cognition with a brief Interview of mental status (BIMS) score of 9 out of a possible score of 15. Resident #20 required assistance with meal set and was dependent for cares.Review of Resident #20 physician orders revealed an order dated 09/03/25 for resident to utilize scoop plate and two handled cup with lid for all meals to increase functional independence.Review of Resident #20's nutritional…

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 interview and facility policy and procedure review, the facility failed to ensure enteral feedings were labeled and dated when the feeding was initiated and hung for administration. This affected three (Resident #10, #39 and #81) of six residents with enteral feedings. The census was 71. Findings include:1. Review of Resident #10's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, depression, anxiety, atrial fib, tracheostomy and gastrostomy. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact (BIMS 15). Requires partial/moderate assistance for oral hygiene, dependent on toileting, shower/bathing, dressing, personal hygiene and substantial maximal assistance for turning and repositioning. Resident was frequently incontinent of bowel and bladder. Review of the physicians orders 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 staff interview and record review, facility failed to follow pain order parameters for Resident #61. The facility also failed to offer non-pharmacological interventions to two Residents (#8 and #61) of two reviewed for pain. Facility census was 71. Findings include: 1.Review of the medical record for Resident #61 revealed an admission date of 07/30/25. Diagnoses included pressure ulcer, diabetes, respiratory failure with hypoxia, lymphedema and anxiety. Review of physician orders on 08/01/25 revealed an order for Oxycodone HCl (opioid) tablet 5 milligram (mg) with instructions to give one every four hours as needed for pain rating of 1-4 with 30 mg daily maximum. Review of physician orders on 08/01/25 revealed an order for Morphine Sulfate (opioid) 20 mg/milliliter (ml) with instructions to give 0.5 ml by mouth every 12 hours as needed for pain of 5-10. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition.…

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, resident and staff interviews and record review, facility failed to ensure resident requests were follow up on in a timely manner. This affected one Resident (#93) of four observed for call lights. Facility census was 71. Findings include Review of the medical record for Resident #93 revealed an admission date of 09/18/25. Diagnoses included osteomyelitis, necrotizing fasciitis, anorexia, and lack of coordination. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 10 indicating impaired cognition. Interview on 09/22/25 at 1:48 P.M. with Resident #93 revealed she wanted something for pain and also wanted the nurse to look at a wound on her leg. Resident was requested to activate her call light to inform staff. Observation on 09/22/25 at 1:51 P.M. Activity Aide (AA) #157 answered the call light and deactivated it. AA answered several other call lights and talked with several staff in the hallway including the assigned nurse. No…

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 and procedure, the facility failed to act upon the pharmacy recommendations in a timely manner. This affected two (Resident #8 and Resident #60) of five residents reviewed for unnecessary medications. he census was 71.Findings include: 1. Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include acute and chronic respiratory failure, tracheostomy, encephalopathy, chronic obstructive pulmonary disease (COPD), seizures, dependence on respirators, schizoaffective disorder and depression. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was moderately impaired. She was independent with eating, required supervision or touching assistance with oral hygiene, and dependent on staff for shower/bathing, toileting, and personal hygiene. Resident #8 was always incontinent of bowel and bladder. Review of Pharmacy Medication Regime Review completed on 11/15/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of facility policy, the facility failed to ensure timely follow up for dental services for one Resident (#32) of three reviewed for dental services. Facility census was 71. Findings include:Review of the medical record for Resident #32 revealed an admission date of 02/03/25. Diagnoses included cardiac arrest, open wound to the buttock, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, retention urine. Resident #32's payer source was Medicare.Review of the plan of care dated 02/06/25 revealed the resident had an impaired dental status as evidenced by dentures. It noted the resident lost some/all natural teeth with interventions to arrange for dental consults and follow up visits by dentistry as needed. Review of dental visit note dated 03/28/25 revealed the resident wore dentures. Review of progress note dated 07/15/25 revealed the resident returned from a hospital stay 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 observation, medical record review, policy review and interview, the facility failed to provide adequate care and services to treat pressure ulcers for Resident #100. This affected one resident (#100) of three residents sampled for pressure ulcers. The facility census was 65. Findings include: Medical record review revealed Resident #100 was admitted on [DATE] with diagnoses including aortic aneurysm, cerebral infarction, respiratory failure with ventilator dependence, contractures, functional quadriplegia and encephalopathy. Review of the Specialty Physician Wound Evaluation and Management Summary dated 09/11/24 revealed Resident #100 had a sacrum Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure wound that had epithelialized and resolved. The specialty physician signed off on care of the resident on this date as the sacrum area had resolved and made recommendations to continue present skin care 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, medical record review, policy review and interview, the facility failed to maintain accurate medical records for Resident #100. This affected one resident (#100) of three residents sampled. The facility census was 65. Findings include: Medical record review revealed Resident #100 was admitted on [DATE] with diagnoses including aortic aneurysm, cerebral infarction, respiratory failure with ventilator dependence, functional quadriplegia and encephalopathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was severely impaired for daily decision-making, had no pressure ulcers and had a pressure relieving device on the bed. Review of the nursing Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #100 developed a right lateral sacrum abscess 1.5 centimeters (cm) in length (l) by 1.0 (cm) in width (w). Review of the physician Progress Note dated 10/17/24 revealed reason for the visit was to address chronic conditions including sacral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to maintain acceptable infection control practices and ensure accurate isolation precaution sign were removed when ordered. This affected two residents (#9 and #103) during random observations. The facility census was 65. Findings include: 1. Medical record review revealed Resident #103 was admitted on [DATE] with diagnoses including primary central nervous system lymphoma, altered mental status, anxiety disorder, malignant neoplasm of overlapping sites of the brain and depression. Review of the electronic Physician Orders dated December 2024 revealed Resident #103 utilized an air mattress to her bed. Review of the Braden Score Evaluation dated 12/21/24 revealed Resident #103 was at low risk for skin breakdown. On 12/26/24 at 8:12: A.M. and 9:58 A.M., observation of Resident #103's room revealed the footboard was missing and the air mattress pump was sitting on the floor with no barrier. The front of the air mattress pump could not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of manufacture's guidelines, the facility failed to dispose expired Covid 19 vaccine syringes. This had the potential to affect any resident receiving a Covid 19 vaccine or booster vaccine. The facility census was 72. Findings Include: Observation on [DATE] at 10:58 A.M. revealed an opened box of Spikevax (Covid 19) vaccine located in the back drawer of the medication storage refrigerator located in the North unit's medication storage room. Inside the opened box were two pre-filled syringes remaining out of the original ten pre-filled syringes with lot number #3032713 and expiration date [DATE]. There were no opened dates observed on the box or on the syringes. Interview on [DATE] at 11:10 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) # 560 confirmed the two pre-filled syringes in the opened box of Spikevax (Covid 19) vaccine with expiration date [DATE]. LPN UM #560 stated the vaccines would be administered on request from resident. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#175) was treated with respect and dignity. This affected one of one resident reviewed for dignity. The facility census was 72. Findings Include: Review of the medical record for Resident #175 revealed an initial admission date of 07/18/24 with the diagnoses including but not limited to human metapneumovirus pneumonia, pneumonitis due to inhalation of food and vomit, pulmonary fibrosis, Parkinsonism, dementia with moderate mood disorder, dystonia, anxiety disorder, depression, presence of neurostimulator, insomnia, hypertension, gastro-esophageal reflux disease, history of malignant neoplasm of prostate, acquired absence of other genital organs, vitamin D deficiency, generalized muscle weakness, dysphagia, unspecified voice and resonance disorder and other symbolic dysfunctions. Review of the resident's admission assessment with baseline plan of care dated 07/18/24 revealed 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 record review, interview and Long Term Care Facility Resident Assessment Instrument 3.0 Manual review, the facility failed to complete an initial comprehensive, accurate standardized Minimum Data Assessment (MDS) within the first 14 days following admission to the facility for two residents (#175 and #177) and failed to accurately assess and code the oral status of one resident (#30) on the annual MDS. This affected three residents (Resident #175,#177, and #20) of 20 sampled residents. The facility census was 72. Findings Include: 1. Review of the medical record for Resident #175 revealed an initial admission date of 07/18/24 with the diagnoses including but not limited to human metapneumovirus pneumonia, pneumonitis due to inhalation of food and vomit, pulmonary fibrosis, Parkinsonism, dementia with moderate mood disorder, dystonia, anxiety disorder, depression, presence of neurostimulator, insomnia, hypertension, gastro-esophageal reflux disease, history of malignant neoplasm of prostate, acquired…

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, medical record review, staff interview, and policy review, the facility failed to comprehensively assess residents for possible medication side effects. This affected two (Resident #11 and Resident #19) of 20 sampled residents. The facility census was 72. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/23/19 and diagnoses of schizophrenia and parkinson's disease. The resident was receiving an antipsychotic medication (Seroquel 250 milligrams daily), an atypical antipsychotic (nuplazid 34 mg daily), an anticonvulsant medication (Depakote 1000 mg daily), an antidepressant/sedative medication (trazodone 50 mg daily), an antianxiety medication (Ativan 1 mg daily), an anxiolytic medication (buspar 15 mg daily), an antidepressant medication (sertraline 100 mg daily), and a sleep aide (melatonin 6 mg daily). Review of a minimum data set assessment of 07/01/24 revealed a brief interview for mental status score of 15 out of 15, indicating intact cognition. Observations on 07/31/24 at 9:01 A.M. and 1:36 P.M. and 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 facility policy review, the facility failed to document the reason for decline in gradual does reduction of antipsychotropic medications for one resident (#8). This affected one (Resident #8) of five residents reviewed for unnecessary medications. The facility census was 72. Findings Include: Review of the medical record for Resident #8 revealed an initial admission date of 03/30/22 with the latest readmission of 01/02/24 with diagnoses including acute and chronic respiratory failure with hypoxia or hyercapnia, Duchenne or [NAME] muscular dystrophy, ileus, protein calorie malnutrition, dependence on ventilator, pain, pleural effusion, acute kidney failure with tubular necrosis, neuromuscular dysfunction, anxiety disorder, hypothyroidism, depression, contracture of muscles, gastrostomy, tracheostomy, anemia, GERD, cardiomyopathy, constipation, tachycardia, contracture of left hand, dysphagia and cognitive communication deficit. Review of the plan of care dated 01/02/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices to prevent the potential spread of infection in the area of droplet isolation. This affected one resident (#175) of three residents reviewed for transmission based precautions (TBP). The facility census was 72. Findings Include: Review of the medical record for Resident #175 revealed an initial admission date of 07/18/24 with the diagnoses including but not limited to human metapneumovirus pneumonia, pneumonitis due to inhalation of food and vomit, pulmonary fibrosis, Parkinsonism, dementia with moderate mood disorder, dystonia, anxiety disorder, depression, presence of neurostimulator, insomnia, hypertension, gastro-esophageal reflux disease, history of malignant neoplasm of prostate, acquired absence of other genital organs, vitamin D deficiency, generalized muscle weakness, dysphagia, unspecified voice and resonance disorder and other symbolic dysfunctions. 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 observation, interview and facility policy review, the facility failed to ensure one resident's (#181) call light was within reach to call staff for assistance. This affected one of 20 sampled residents. The facility census was 72. Findings Include: On 07/30/24 at 1:59 P.M., observation of Resident #181 revealed his call light was laying on the floor on a floor mat next to his bed out of reach. On 07/30/24 at 2:30 P.M., interview with State Tested Nursing Assistant (STNA) #553 revealed the resident had no speech, was dependent on staff for activities of daily living and the call light was the only means to alert staff of any needs. STNA #553 verified the resident's call light was on the floor out of his reach. On 07/31/24 at 1:59 P.M., observation of Resident #181 revealed the resident's call light was laying on the floor on a floor mat next to his bed. STNA #590 verified the resident's call light was not within reach and had no ability to summon facility staff for needs. Review of the facility policy titled, Call Lights: Accessibility and Timely Response, dated 04/01/22…

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 record reviews, facility policy, family and staff interviews the facility failed to allow Resident #61 and #31 to exercise their right to be informed, choice and participate in the care being provided. This affected two of two residents, (#61, #31) reviewed for planning and implementing care. The facility census was 70. Findings: 1. Record review of Resident #61 revealed an admission date of 05/01/23 with diagnoses including encephalopathy, gastrostomy tube, hemiplegia and hemiparesis following cerebral infarction affecting right side, chronic respiratory failure, seizures, chronic kidney disease, pressure ulcer of sacral region, anorexia, anemia, dysphagia, hypertension, aphasia, candidiasis of mouth and contracture of muscle of right hand. Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 61's Brief Interview for Mental Status (BIMS) score was not calculated due to the resident's inability to answer the question, indicating he had a severe cognitive…

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, interviews, and record review the facility failed to document communication of change of condition requiring new antibiotic treatments of one resident (#64) out of one resident reviewed for change in condition and failed to provide failed to provide documentation of communication for resident's dental service needs and antibiotic orders for one resident (#61) out of one reviewed for dental services. The facility census was 70. Findings include: 1.Resident #64 was admitted to the facility on [DATE]. Diagnoses included Acute Respiratory failure with hypoxia, critical illness myopathy, dependence on ventilator, obstructive sleep apnea, heart failure, hypertension, repeated falls, gastroesophageal reflux disease, obstructive and reflux uropathy, tracheostomy, gastrostomy, sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed mild cognitive impairment with no delirium or psychosis. Resident #64 had total dependence on assistance for bed…

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, observations, and facility comprehensive care plan policy, this facility failed to develop a person center care plan to accurately reflect a resident target behavior of yelling. This affected one (Resident #30) of the two residents reviewed for mood and behavior care. The facility census was 70. Findings included: Review of the medical record for Resident #30 revealed an admission date of 05/24/23. Diagnosis included Alzheimer's disease, anxiety, Pseudobulbar Affect (symptoms include frequent and uncontrolled crying and/or laughing), and major depressive disorder recurrent with severe psychotic symptoms. Review of Resident #30's behavior monitoring order dated 05/25/23 and discontinued 08/09/23 revealed Behavior Monitoring due to anxiolytic medication, document number of episodes per shift of target behavior, target behavior includes, 1-withdrawn, 2-restlessness, 3-excessive worrying. Review of Resident #30's behavior monitoring order dated 08/09/23 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, dialysis center interview, and facility Dialysis policy review, this facility failed to ensure Dialysis care plans were up to date to accurately reflect residents current Dialysis center and treatment days. This affected one (Resident #54) of the one resident reviewed for Dialysis care. Facility census was 70. Findings included: Review of the medical record for Resident #54 revealed an admission date of 11/16/22. Diagnoses included end stage renal disease, anemia, personal history of venous thrombosis and embolism, decreased white blood cell count, thrombocytopenia, dependence of oxygen, acute upper respiratory infection, and dependence on renal dialysis. Review of the plan of care dated 11/16/22 and revised on 12/02/22 revealed Resident #54 had potential for complications related to the diagnosis of renal failure/end stage renal disease requiring Dialysis treatment. Dialysis services were to be completed at Fresenius Kidney Care on Tuesday, Thursday, and Saturday…

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 and staff interviews, the facility failed to provide activities services for two out of two residents, (Resident #17 and #35 ) reviewed for activities services. The census was 70. Findings: 1. Record review revealed Resident #17 was admitted to the facility 7/26/14 with diagnoses including Diabetes Mellitus, hemiplegia and hemiparesis, cerebrovascular disease, heart failure, major depressive disorder, chronic obstructive pulmonary disease, chronic pain syndrome, and cognitive communication deficit. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Review of the annual activity evaluation completed on 09/01/22 revealed that Resident #17 preferred activities in own room and outside including spiritual or religious, walking/wheeling out or indoors, and watching TV. Review of plan of care dated 08/01/14 revealed an activity deficit, with interventions in place including providing 1 on 1 as needed and to invite or encourage or assist 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 interview and record review the facility failed to timely implement a new treatment for Resident #40's pressure ulcer as recommended by the wound doctor. This affected one resident (#40) of eight residents with pressure ulcers reviewed. The facility census was 70. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/05/22 and diagnoses including anoxic brain damage, dependence on respirator, type two diabetes mellitus, contracture of bilateral hands and ankles, neuromuscular dysfunction of the bladder, anxiety, and cardiac arrest. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was comatose. She was totally dependent on staff for all activities of daily living. Review of the plan of care dated 07/13/23 revealed Resident #40 had a pressure ulcer to her right buttock. Interventions included an air mattress as ordered, evaluating for pain and providing interventions, continuing wound treatment as ordered, 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 medical record review, observations, staff interview, facility fall investigations, and facility fall policy, the facility failed to ensure fall interventions were in place for residents with a history of falls or who were at risk for falls. This affected two (Resident #36 and #24) of the three residents reviewed for fall interventions. The facility census was 70. Findings include: 1) Review of the medical record for Resident #36 revealed an admission date of 11/15/22. Diagnoses included dementia without behavioral disturbances, encephalopathy, weakness, adult failure to thrive, repeated falls, abnormalities of gait, and unsteadiness on feet. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 indicating a severely impaired cognition for daily decision making abilities. Resident #36 required extensive assistance from one staff member for bed mobility, dressing, personal hygiene, and total…

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, Dialysis center agreement review and facility Dialysis policy, this facility failed to have a signed agreement between the facility and dialysis center affecting one (Resident #54) of the one resident reviewed for Dialysis services. The facility census was 70. Findings included: Review of the medical record for Resident #54 revealed an admission date of 11/16/22. Diagnoses included end stage renal disease, anemia, personal history of venous thrombosis and embolism, decreased white blood cell count, thrombocytopenia, dependence of oxygen, acute upper respiratory infection, and dependence on renal dialysis. Review of Resident #54's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision making abilities. Resident #54 was noted to be receiving diuretic medication daily and receiving Dialysis services. Review of Resident #54's Dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure pain medication parameters were followed for Resident #62. This affected one resident (#62) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of the medical record revealed Resident #62 had an admission date of 05/05/23 with diagnoses including acute and chronic respiratory failure with dependence on respirator, paraplegia, total retinal detachment, traumatic cerebral edema, dysphagia, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 had intact cognition. Review of the plan of care dated 06/10/23 revealed Resident #62 had the potential for alteration in comfort or had actual alteration in comfort related to inability to move independently, skin alteration, surgical site, and trauma. Interventions included asking the resident regarding location, severity, and type of pain, attempting non-pharmacologic interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility policy review, the facility failed to complete behavior monitoring for two residents (#16 and #30) on antianxiety medication. This affected two residents (#16 and #30) of two residents reviewed for mood and behavior. The facility census was 70. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 03/22/22 with diagnoses including acute and chronic respiratory failure with dependence on respirator, depression, type two diabetes, heart failure, chronic kidney disease, dysphagia, and traumatic subdural hemorrhage. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition. She received antianxiety and antidepressant medications. Review of the plan of care dated 04/07/22 revealed Resident #16 had a potential for adverse side effects of psychotropic drug use. She had anxiolytic and antidepressant drug therapy related to depression and anxiety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview ,record review, and facility policy review, the facility failed to document wound treatments as completed for three residents (#40, #48, and #60). This affected three residents (#40, #48, and #60) of eight residents reviewed for pressure ulcers. The facility further failed to provide documentation of oral assessments and usage of antibiotics and communication for resident's dental service needs and antibiotic orders for one resident (#61) out of one reviewed for dental services. The facility census was 70. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 09/05/22 and diagnoses including anoxic brain damage, dependence on respirator, type two diabetes mellitus, contracture of bilateral hands and ankles, neuromuscular dysfunction of the bladder, anxiety, and cardiac arrest. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was comatose. She was totally dependent on staff for all activities of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failed to ensure the urine collection bags were kept off the floor. This was observed for two residents (#33 and #60) out of 14 residents with indwelling catheters. The facility census was 70. 1. Resident #33 was admitted to the facility on [DATE] with the most recent readmission [DATE]. Diagnoses include acute and chronic respiratory failure with hypoxia, dependence on ventilator, dementia, myoclonus, dysphagia, seizures, chronic kidney disease, contracture of left knee, left shoulder, and right shoulder, cystostomy, neurogenic bladder and urine retention, tracheostomy, and gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 is in a persistent vegetative state with no discernible consciousness. Resident #33 is totally dependent for all mobility and sell care categories. Resident #33 has an indwelling catheter and is always incontinent of stool. Observation on 08/09/23 at 09:34 A.M. revealed Resident #33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility antibiotic stewardship policy review, the facility failed to ensure residents who had orders for receiving antibiotic cream had the location for the cream to be applied and a stop date for the antibiotic cream. This effected one (Resident #222) of the five residents reviewed for appropriate medication regimen. The facility census was 70. Findings included: Review of the medical record for Resident #222 revealed an admission date of 07/26/23. Diagnoses included a stable burst fracture of first lumbar vertebra, confusion of part of head, laceration without foreign body of right hand, and falls. Review of Resident #222's 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating an intact cognition for daily decision making abilities. Review of Resident #222's physician orders for August 2023 revealed a order for Bacitracin ointment, 500 units per gram. Apply to per…

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.