Ayden Healthcare Of Piqua

Based on medical record review, observation, resident representative interview, staff interview, and review of the facility policy, the facility failed to provide routine dental services. This affected one (Resident #54) of two residents reviewed for dental services. The facility census was 76 residents. Findings include: Review of the medical record for Resident #54 revealed an admission date of 11/01/23 with diagnoses including right hemiparesis, dysphagia, hypertension, seizure disorder, and diabetes mellitus. Review of the dental note for Resident #54 dated 03/20/24 revealed the resident was seen by the dentist and had 10 teeth extracted. Further review revealed Resident #54's remaining teeth would need to be extracted, and physician clearance was left at the facility. Review of the dental note for Resident #54 dated 09/30/24 revealed the dentist was in the facility but the resident was not seen because the planned services were unable to be completed in the resident's room. Review of the dental assessment for Resident #54 dated 02/05/25 revealed the resident had some teeth in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, observation, review of online resources from Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to provide adequate infection control techniques during a resident's dressing change. This affected one (#20) resident of the three residents reviewed for infection control. The facility also failed to ensure staff properly discarded personal protective equipment (PPE) after completing a resident's dressing change who was in Enhanced Based Precautions (EBP). This had the potential to affect the 19 other residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) housed on the 100-hall who the facility identified as not being in EBP. The facility census was 80. Findings included: Review of record revealed Resident #20 had admission date on 03/17/25. Diagnoses included orthopedic aftercare from surgical amputation left leg below knee, acute osteomyelitis in left ankle and foot, 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 medical records, observation, staff interviews, review of employee training records, review of employee personnel files, review of manufacturer guidelines for a sit-to-stand lift, and review of facility policy, the facility failed to safely transfer a resident using a sit-to-stand lift. This affected one (#30) resident of the three residents reviewed for transfers. The facility identified three residents were dependent on staff for transfers. The facility census was 80. Findings included: Review of the medical record for Resident #30 revealed an admission date 11/25/24. Diagnoses included metabolic encephalopathy, muscle weakness, unsteadiness on feet, type two diabetes, and multiple fractures of ribs. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired as evidence by a Brief Interview of Mental Status (BIMS) of 02. Resident #30 was dependent on staff for transfers and required substantial to maximal assistance for other 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 medical record review, resident interview, review of the Certification and Licensure System (CALS), staff interview and review of facility policy, the facility failed to report an allegation of inappropriate staff touching as potential resident abuse to the Ohio Department of Health (ODH). This affected one resident (#38) of three residents reviewed for abuse. The facility census was 83. Findings include: Review of Resident #38's medical record revealed an admission date of 09/17/24. Diagnoses included chronic respiratory failure, morbid (severe) obesity and Type II diabetes. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #38 was cognitively intact, required set-up assistance with eating and oral hygiene, partial staff assistance with bed mobility and transfers, and substantial staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and wheelchair mobility. Review of the physician orders revealed an order dated 02/22/25 for No Male Care for showers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, review of the Certification and Licensure System (CALS), medical record review, staff interview, and review of facility policy, the facility failed to investigate an allegation of inappropriate staff touching as potential resident abuse. This affected one resident (#38) of three residents reviewed for abuse. The facility census was 83. Findings include: Review of Resident #38's medical record revealed an admission date of 09/17/24. Diagnoses included chronic respiratory failure, morbid (severe) obesity and Type II diabetes. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #38 was cognitively intact, required set-up assistance with eating and oral hygiene, partial staff assistance with bed mobility and transfers, and substantial staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and wheelchair mobility. Review of the physician orders revealed an order dated 02/22/25 for No Male Care for showers every shift for Post traumatic…

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 policy review, the facility failed to have physician visits and nurse practitioner visits notes signed in a timely manner. This affected three (#06, #34, and #60) of three residents reviewed for provider visits. The facility census was 84. Findings include: 1. Medical record review for Resident #06 revealed he was admitted to the facility on [DATE]. Diagnoses included myocardial infarction, diabetes mellitus, pulmonary embolism, essential primary hypertension, hyperlipidemia, respiratory failure, obstructive sleep apnea, major depressive disorder, pleural effusion chronic kidney disease, hernia, and morbid obesity. Review of the Minimum Data Set (MDS) assessment, dated 02/10/25, revealed Resident #06 was cognitively intact. Review of the progress notes for Resident #06 revealed he was assessed by the facility physician on 02/11/25; however, the document was not signed until 02/15/25. Further review revealed Resident #06 was assessed by 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 record review, observations, staff interviews and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff followed proper infection control procedures during incontinence care. This affected one (#16) out of three residents review for infection control. The facility census was 82. Findings include: Review of medical record for Resident #16 revealed admission date of 11/01/22. Diagnoses include chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The resident remained in the facility. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of eight out of 15 indicating impaired cognition. Resident #16 required set up for eating, maximum assistance with bed, transfers and was dependent for toileting hygiene. Resident #16 was frequently incontinent of bladder and always incontinent of bowel. Observation was made on 12/18/24 at 10:58…

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 infection control records, observations, staff interviews, review of electronic mail (e-mail) correspondence, review of facility policies and procedures, review of the Center for Disease Control and Prevention CDC) guidance, and review of Ohio Department of Health's (ODH) guidance for reporting infectious diseases, the facility failed to develop and implement effective infection control policies and practices which includes a failure to ensure cleaning schedules for ice buckets were developed/implemented, failure to ensure storage areas were maintained in a sanitary manner to potentially prevent rodent/animal contamination, failure to ensure the handwashing sink in the kitchen was appropriately functioning, failure to develop written policies and procedures which included when and to who potentially communicable diseases should be reported, and failure to ensure the local health department was notified in a timely manner of a Campylobacter illness outbreak. This affected a total of nine (Resident #10, #32, #43, #45, #48, #54, #61, #65 and #66) residents…

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 and resident interviews, and policy review, the facility failed to notify residents of room changes. This affected two (#35 and #49) out of the three residents reviewed for room changes. The facility census was 71. Findings included: 1. Review of the medical record for Resident #35 revealed an admission date of 03/01/23 with medical diagnoses of Coal worker's pneumonoconiosis, Parkinson's disease, atherosclerotic heart disease (ASHD), and atrial fibrillation. Review of the medical record for Resident #35 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #35 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene, bathing, and bed mobility and was dependent for transfers. Review of the medical record for Resident #35 revealed Resident #35 moved rooms on 11/28/23. Review of the medical record revealed no documentation to support Resident #35 was notified or approved of the room change.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, review of the facility Self-Reported Incidents (SRI), and policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse. This affected two (#11 and #62) out of the three residents reviewed for abuse. The facility census was 71. Findings included: 1. Review of the medical record for Resident #62 revealed an admission date of 01/07/22 with medical diagnoses of Alzheimer's disease, legal blindness, hypertension, and adult failure to thrive. Review of the medical record for Resident #62 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #62 had moderate cognitive impairment and required supervision with eating and substantial staff assistance with toilet hygiene, bed mobility, transfers, and bathing. Review of the medical record for Resident #62 revealed a Social Service note dated 01/11/24 at 2:07 P.M. which stated an attempt was made to contact the resident's power of attorney (POA) 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 medical record review, observations, and staff interviews, the facility failed to provide adequate behavioral supervision for Resident #35, in accordance with the residents physician orders. This affected one (#35) out of three reviewed for sexual behaviors. The facility census was 71. Findings included: Review of the medical record for Resident #35 revealed an admission date of 03/01/23 with medical diagnoses of Coal worker's pneumonoconiosis, Parkinson's disease, atherosclerotic heart disease (ASHD), and atrial fibrillation. Review of the medical record for Resident #35 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #35 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene, bathing, and bed mobility and was dependent for transfers. Review of the medical record for Resident #35 revealed a nurse's note dated 01/11/24 at 12:13 P.M. which stated the nurse was notified that Resident #35 was observed being…

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 interview, self-reported incident review, and review of a facility policy, the facility failed to report all allegations of abuse to the administrator and other officials in a timely manner. This affected two (#3 and #4) of six residents reviewed for abuse. The census was 75. Findings include: 1. Record review of Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 include chronic obstructive pulmonary disease, diabetes, anxiety, chronic respiratory failure, and heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required a two-person assist for activities of daily living (ADLs). Further review revealed the resident received hospice services and was on supplemental oxygen. Interview on 09/14/23 at 11:09 A.M., with Resident #2 stated she was not in the room on 07/13/23 when the alleged abuse from the Administrator towards Resident #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, the facility failed to ensure Administration administered the facility in a manner to maintain the highest psychosocial well-being of the residents. This affected three (#2, #4, and #5) of six residents reviewed for psychosocial well-being. The census was 75. Findings include: 1. Record review of Resident #2 revealed the resident was admitted to the facility on [DATE] as a readmission. Diagnoses for Resident #2 included aftercare following joint replacement surgery, muscle weakness, depression, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required a one-person assist for activities of daily living (ADLs). Interview on 09/14/23 at 11:09 A.M., with Resident #2 stated she reported the Administrator being inappropriate with a therapy worker, stopping the therapist in the hall, staring at her chest, and interrupting her therapy session. Resident #2…

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 interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow infection control standards to prevent the spread of COVID-19, by not having staff wear appropriate personal protective equipment (PPE). This had the ability to affect all the residents of the facility. The census was 72. Findings include: Observation of staff members upon entrance to the facility on [DATE] at 8:05 A.M., revealed no staff members were wearing eye protection. Tour of the facility on 08/29/22 at 9:20 A.M., revealed multiple working in the facility were currently not wearing any eye protection. Interview with Licensed Practical Nurse (LPN) #84 on 08/29/22 at 9:25 A.M., confirmed she was not wearing any eye protection while caring for residents. LPN #84 stated she was told she was not required to wear any due to county COVID-19 level. Interview with LPN #66 on 08/2922 at 9:29 A.M., confirmed she was not wearing any eye protection. LPN #66 stated eye…

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 walk in freezer was sanitary and free of water leaking onto stored food and drinks. This had the potential to affect 67 of 72 residents residing in the facility who receive their meals from the kitchen. The facility identified five (#19, #65, #27, #34 and #26) residents who receive no food from the kitchen. The facility census was 72. Findings include Observation on 08/29/22 at 9:15 A.M., of the walk-in freezer revealed a gray dish pan collecting water dripping from the freezer unit on the tip shelf of a storage unit. Water was dripping into the pan from a copper-colored line coming from the unit. The freezer unit had approximately three inches of ice formation on the underneath side of the unit. Directly under the gray dishpan was individually frozen juice cups that were sitting in a cardboard box that was wet from the leaking water. All other boxes in the walk in freezer were coated with a think layer of ice. The ceiling of the walk-in freezer had collections of clear liquid hanging in droplet shapes that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the medical record contained the advanced directive information. This affected one (#319) of one resident reviewed for advanced directives. The facility census was 72. Findings include: Review of medical record for Resident #319 revealed admission date of 08/19/22, with diagnoses including orthopedic aftercare, right femur fracture, congestive heart failure, type two Diabetes Mellitus, depression and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two person assistance bed mobility, transfers, toileting and supervision for eating. Review of the care plan updated 08/31/22, revealed Resident #319 choose to be a Do Not Resuscitate (DNR) Comfort Care Arrest (CCA). Review of physician orders for Resident #319 revealed a full code order was place on 08/19/22 and discontinued on 8/25/22. A DNR - no directions specified for order was placed 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 record review and staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) website, the facility failed to issue an Advanced Beneficiary Notice (ABN) as required. This affected two (#15 and #11) of three residents reviewed. The facility census was 72. Findings include: Review of medical record for Resident #15 revealed a re-admission date of 07/08/22, with diagnoses including stroke and hemiplegia/paresis affecting left non dominant side, Diabetes Mellitus type two and depression. Review of records for Resident #15 revealed a Notice of Medicare Non Coverage (NOMNC) was issued with an end of service date of 03/10/22 and signed by Resident #15 on 03/08/22. No Advanced Beneficiary Notice (ABN) was provided. Review of medical record for Resident #11 revealed admission date of 03/11/21, with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, depression and hypertension. Review of records for Resident #11 revealed a Notice of Medicare Non-Coverage (NOMNC) was issued with an end of service of 07/22/22 and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to issue bed hold notification to a resident. This affected one (#34) of seven reviewed for hospitalization. The census was 72. Findings include: Review of Resident #34's medical record revealed an admission date of 07/04/22. Diagnoses listed included hypertension, hypothyroidism, chronic kidney disease, type two diabetes mellitus, and vascular dementia. Resident #34 was assessed as being moderately cognitively impaired and requiring extensive assistance with activities of daily living (ADLs) in a Minimum Data Set (MDS) assessment dated [DATE]. Further review revealed Resident #34 was transferred to a local hospital for evaluation on 07/20/22. There was no documentation of a bed hold notice being issued Resident #34 or her representative. Interview on 08/31/22 art 9:48 A.M., with Business Office Manager (BOM) #17 confirmed that Resident #34 was not issued a bed hold notice when discharged to the hospital on [DATE]. BOM #17 stated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and review of policy, then facility failed to assess and monitor a resident's bruising. This affected one (#30) of four residents reviewed for non-pressure related skin concerns. The census was 72. Findings include: Review of Resident #30's medical record revealed an admission date of 05/10/22. Diagnoses listed included type two diabetes mellitus, hyperlipidemia, major depressive disorder, emphysema, kidney failure, and age-related osteoporosis. Resident #30 was assessed as being cognitively intact and requiring limited assistance with personal hygiene in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Observation on 08/29/22 at 11:15 A.M., revealed bruising to Resident #30's bilateral hands, wrists, and lower forearms. Interview on 08/31/22 at 1:29 P.M., with Resident #30 stated the bruising to her hands, wrists, and forearms was from past blood draws. Further review of Resident #30's medical record revealed no documentation an any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure a palm protector was applied as ordered. This affected one (#27) of three residents reviewed for limited range of motion and supportive devices. The facility census was 72. Findings include: Medical record review for Resident #27 revealed an admission date on 12/08/20, with diagnoses including: stroke, gastronomy malfunction, hypertension, dementia, disturbances of salivary secretions, glaucoma, flaccid hemiplegia, type two diabetes, and contracture of left hand. Review of comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 revealed severely impaired cognition. Resident #27 required total assist for bed mobility, transfers, eating and toileting. Resident #27 has functional limitation of range of motion on one side. Review of the plan of care for Resident #27 dated 08/03/17 revealed the resident has activity of self-care deficit as evidenced by inability to care for self-related to physical…

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, medical record reviews, resident and staff interviews, and review of facility policies, the facility failed to ensure medications were securely stored. This affected two (#39 and #72) of two resident reviewed for medications. The facility census was 72. Findings include: Review of medical record for Resident #39 revealed admission date of 05/15/20, with diagnoses including: stroke with dominant right side hemiplegia/paresis, depression and polyneuropathy. The resident remains in the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition and required supervision for all activities of daily living. Review of physician orders for August 2022, revealed Resident #39 had an order for Gabapentin (polyneuropathy) 300 milligram capsule three times daily. Observation on 08/29/22 at 10:11 A.M., revealed one capsule in a clear, unmarked medicine cup on Resident #39's bedside table. Interview on 08/29/22 at 10:13 A.M., with Licensed…

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 and physician, dietitian and staff interviews, the facility failed to assess a resident for personal food preferences and provide a diet to meet the nutritional needs. This affected one (#319) of one resident reviewed reviewed for nutrition. The facility census was 72. Findings include: Review of medical record for Resident #319 revealed admission date of 08/19/22, with diagnoses including: orthopedic aftercare, right femur fracture, congestive heart failure, type two Diabetes Mellitus, depression and anxiety. The resident remains in the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two person assistance bed mobility, transfers, toileting and supervision for eating. Review of a care plan updated 08/31/22 revealed Resident #319 was a potential for alteration in nutrition/hydration with interventions to provide diet as ordered. Diabetes Mellitus with interventions to monitor 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, observation and Nurse Practitioner and staff interviews, the facility failed to maintain accurate medical records. This affected one resident (#29) of 79 residents records reviewed during the annual recertification. The facility census was 72. Findings included Medical record review for Resident # 29 revealed an admission date on 12/01/18, with diagnoses including: type two Diabetes Mellitus with chronic kidney failure, bipolar disorder, above the right knee amputation, morbid obesity, anxiety disorder and hypertensive heart disease. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #29 dated 07/14/22 revealed an impaired cognition. Resident #29 required extensive assist for bed mobility, dressing and toileting with two staff members, resident was supervised for eating. No dialysis was coded. Review of the plan of care for Resident #29 dated 06/23/17 was silent for dialysis treatment. Review of the active physician orders for Resident #29 for the month of September 2020 was silent for orders related to the treatment of 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 medical record review, staff interview, review of Self-Reported Incidents (SRI), and review of the facility policy, the facility failed to follow and implement the facility's abuse policy to ensure residents were protected from potential sexual abuse from other residents. This affected two (Resident #13 and Resident #20) of three residents reviewed for abuse. The facility census was 59. Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, weakness, diabetes, vascular dementia without behaviors, hypertension, and muscle weakness. Review of the baseline care plan dated 06/13/19 revealed the Director of Nursing (DON) completed the care plan and documented Resident #13 had impaired cognition related to dementia. Review of the care plan dated 06/14/19 revealed Resident #13 had impaired thought processes characterized by deficit in memory, judgement, decision making related to vascular dementia.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of Self-Reported Incidents (SRI), and review of the facility policy, the facility failed to report incidents of potential resident to resident sexual abuse. This affected two (Resident #13 and Resident #20) of three residents reviewed for abuse. The facility census was 59. Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, weakness, diabetes, vascular dementia without behaviors, hypertension, and muscle weakness. Review of the baseline care plan dated 06/13/19 revealed the Director of Nursing (DON) completed the care plan and documented Resident #13 had impaired cognition related to dementia. Review of the care plan dated 06/14/19 revealed Resident #13 had impaired thought processes characterized by deficit in memory, judgement, decision making related to vascular dementia. Interventions for the focus included the resident needs supervision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of Self-Reported Incidents (SRI), and review of the facility policy, the facility failed to investigate incidents of potential resident to resident sexual abuse. This affected two (Resident #13 and Resident #20) of three residents reviewed for abuse. The facility census was 59. Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, weakness, diabetes, vascular dementia without behaviors, hypertension, and muscle weakness. Review of the baseline care plan dated 06/13/19 revealed the Director of Nursing (DON) completed the care plan and documented Resident #13 had impaired cognition related to dementia. Review of the care plan dated 06/14/19 revealed Resident #13 had impaired thought processes characterized by deficit in memory, judgement, decision making related to vascular dementia. Interventions for the focus included the resident needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident's Minimum Data Set (MDS) assessments were accurately coded. This affected three (Resident #6, #24, and #51) of fifteen residents reviewed for MDS accuracy. The facility census was 59. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 02/23/18. Medical diagnoses included Alzheimer's disease, insomnia, dementia, chronic obstructive pulmonary disease, peripheral vascular disease, pain left shoulder, major depressive disorder, anxiety disorder, and atherosclerotic heart disease of coronary artery. Review of the resident's physician's orders revealed an order dated 04/30/19 for tramadol (opioid) three times daily for pain. Review of the resident's 07/13/19 quarterly MDS, revealed she received no pain medication during the assessment period. Review of section N, medications, revealed she received opioid medications seven of seven days of the assessment period. Interview with MDS Nurse #477…

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 reviews, staff interview, and review of a facility policy, the facility failed to ensure timely treatment of a resident's urinary tract infection. This affected one (Resident #35) of two residents reviewed for urinary tract infections. The facility census was 59. Findings include: Review of Resident #35's medical record revealed an admission date of 08/08/19. Medical diagnoses included encounter for orthopedic aftercare following surgical amputation, diabetes mellitus, polyneuropathy, heart failure, epilepsy, anxiety, and chronic obstructive pulmonary disease. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 10, indicating moderate impairment in cognition. The resident required extensive assistance for toilet use and personal hygiene. She was frequently incontinent of urine. Review of the resident's physician's orders revealed an order dated 09/28/19 for urinalysis (UA) with culture and sensitivity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of a facility policy, the facility failed to ensure timely physician response to pharmacy recommendations. This affected two (Resident #6 and #5) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 02/23/18. Medical diagnoses included Alzheimer's disease, insomnia, dementia, chronic obstructive pulmonary disease, peripheral vascular disease, pain left shoulder, major depressive disorder, anxiety disorder, and atherosclerotic heart disease of coronary artery. Review of the resident's pharmacy recommendations revealed a recommendation written 04/17/19 for the resident's ferrous sulfate 325 milligrams (mg) twice daily. The recommendation indicated doses above 325 mg daily were not absorbed and contraindicated in geriatric resident's due to constipation. The physician did not respond to the recommendation until 05/10/19, and agreed with…

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