Country Lane Gardens Rehab & Nursing Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and policy review, the facility failed to provide medications as ordered for Resident #9. This affected one resident (#9) of five residents reviewed for unnecessary medications. The facility census was 82.Findings include: Review of Resident #9's medical record revealed an admission date of 07/10/25 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, major depressive disorder, opioid dependence, anxiety disorder, and long term use of antibiotics.Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #9's physician order dated 07/10/25 revealed an order for Amitriptyline (antidepressant) oral tablet 50 milligrams (mg) two tablets by mouth at bedtime for depression.Review of Resident #9's physician order dated 02/21/26 revealed an order for Sevelamer Carbonate (phosphate binder) 800 mg two tablets before meals for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure physician oversight for medications prescribed from an outside prescriber for Resident #75 and to failed to ensure parameters were followed for blood pressure medications for Resident # 9 and Resident #29. This affected three Residents (#9, #29 and #75) of 7 reviewed for unnecessary medications. The facility census was 82.Findings include:1. Review of the medical record for Resident #75 , revealed an admission date of 08/12/25. Diagnoses included but were not limited to dementia, muscle weakness generalized, adult failure to thrive and poly osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a the resident had moderate cognitive impairment, required supervision or touching assistance with toilet hygiene, bed mobility, and transfers with total dependence with shower/bathe self. Review of the active plan of care for Resident #75 revealed no interventions for monitoring 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.

Based on record review, review of pharmacy recommendations, interview, and policy review, the facility failed to ensure laboratory tests were completed as ordered and the physician was notified of incomplete laboratory tests. This affected one resident (Resident #89) of five reviewed for unnecessary medications. The facility census was 82. Findings include:Review of Resident #89's record revealed an admission date of 11/12/25 and diagnoses that included but were not limited to major depressive disorder, generalized anxiety disorder, schizoaffective disorder, schizoaffective disorder bipolar type, dementia in other diseases classified elsewhere, restlessness and agitation. Review of Minimum Data Set (MDS) 3.0 dated 11/12/25 revealed Resident #89 had a Brief Interview of Mental Status score of nine indicating the resident was not cognitively intact. Review of pharmacy recommendations for Resident #89 revealed a Medication Regimen Review (MRR) dated on 01/19/26 for Atorvastatin (used to lower cholesterol) 80 milligrams (mg) one tab by mouth daily with a request to order a lipid panel…

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, and staff interview, the facility failed to ensure routine dental appointments occurred for all residents. This affected one (Resident #59) of one resident reviewed for dental services. The census was 82.Findings Include:Resident #59 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease, sleep apnea, lymphedema, anxiety disorder, hyperlipidemia, post traumatic stress disorder, bipolar disorder, hypertension, delusional disorder, paranoid personality disorder, insomnia, and irritable bowel syndrome. Review of her minimum data set (MDS) assessment, dated 12/18/25, revealed she was cognitively intact.Review of Resident #59's dental appointment records revealed she had an initial appointment completed on 12/04/24. She was scheduled for another appointment on 12/10/25, but the appointment was cancelled due to Resident #59's refusal on that day. There were no other appointments…

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 interview and record review the facility failed to implement antibiotic stewardship regarding antibiotic use. This affected one (Resident #8) of one resident reviewed for antibiotics. The facility census was 82.Findings include:Review of the medical record for Resident #8 revealed an admission date of 12/16/25 with diagnoses including acute respiratory failure with hypoxia, morbid (severe) obesity, neuromuscular dysfunction of bladder, stage IV pressure ulcer of right buttock, congestive heart failure, atrial fibrillation, paraplegia, and tracheostomy status. Review of the most recent minimum data set (MDS) completed 12/23/25 revealed the resident had intact cognition and had an indwelling foley catheter.Review of the physician's orders revealed Resident #8 had an order for Ciprofoxacin (antibiotic) 500 milligrams (mg) twice daily for 14 days dated 02/17/26 through 03/03/26.Review of the medical record revealed hospital paperwork dated 02/17/26 with urinalysis results with no urine culture. Interview on 03/04/2026 at 2:12 P.M. with regional nurse #237 revealed the 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.

Based on observation, medical record review, and staff, and resident interview, the facility failed to maintain a homelike environment for residents by ensuring the facility supplied sufficient hot water for resident bathing and laundry needs. This deficiency had the potential to affect all 81 residents residing in the facility. The census was 81. Findings include:Observation and interview on 01/14/26 from 10:15 A.M. through 10:25 A.M. revealed the water temperature from Resident #60's bathroom faucet was tepid to touch. Interview with Resident #60 at the time of the observation confirmed the water in the resident's room was sometimes too cold. Interview on 01/14/26 at 10:28 A.M with Certified Nurse Aide (CNA) #141 confirmed the facility had issues with the boiler at least once every week, since at least March 2025. CNA #141 stated nursing management had previously advised staff that if the hot water was not working, to reschedule the assigned residents' baths and showers for the residents' comfort. She confirmed several residents have complained about the lack of hot water because…

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, interview, and facility policies review, the facility failed to ensure residents were not physically restrained. This affected one (#10) of three residents reviewed for abuse. The facility census was 84. Findings Include:Review of the medical record for the Resident # 10 revealed an admission date of 11/18/25. Diagnoses included Type II Diabetes, morbid obesity, bipolar disorder and depression. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] and discharged MDS dated [DATE] revealed Resident #10's brief interview of mental status (BIMS) was not recorded. Review of hospital documentation dated 11/22/25 revealed Resident #10 was alert and oriented three times (person, place and time). He used a walker and wheelchair to transport himself throughout the facility and required one person supervision for activities of daily living. Review of nursing facility progress notes dated 11/22/25 from 11:10 A.M. through 11:30 A.M. revealed Resident #10 was in the hall yelling he…

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, interview, and facility policy reviews, the facility failed to notify the State Agency of an allegation of abuse. This had the potential to affect one resident (#10) of three residents reviewed for abuse. The census was 84. Findings Include: Review of the medical record for the Resident # 10 revealed an admission date of 11/18/25. Diagnoses included Type II Diabetes, morbid obesity, bipolar disorder and depression . Review of his admission Minimum Data Set (MDS) assessment dated [DATE] and discharged MDS dated [DATE] revealed Resident #10's brief interview of mental status (BIMS) was not recorded. Review of hospital documentation dated 11/22/25 revealed Resident #10 was alert and oriented three times (person, place and time). He used a walker and wheelchair to transport himself throughout the facility and required one person supervision for activities of daily living. Review of Resident #10's medical record revealed no physician order for a restraint and no documented incident where 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 record review, observations, and staff interview, the facility failed to ensure residents were free from significant medication errors when their full course of antibiotics would not be given. This affected two of three sampled residents (Residents #51 and #52). The census was 84.Findings Include:1.Review of the medical record for Resident #51 revealed an admission date of 07/21/25 and diagnoses including chronic obstructive pulmonary disease, morbid obesity, asthma, and chronic respiratory failure with hypoxia.Review of nursing progress notes revealed on 12/05/25 at 4:18 P.M. the resident was noted with cough/congestion this shift. Minimal relief from nebulizer treatments. Lungs with diminished bases bilaterally. Scattered rhonchi (sounds caused by constricted airways) noted throughout, some cleared with cough. Sputum light yellow to brown. Call to Certified Nurse Practitioner with new orders for stat chest X-ray. On 12/06/25 at 3:24 P.M. the notes stated chest X-ray received. Physician contacted and new order for antibiotics. Review of physician's orders revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, review of self-reported incidents (SRI), interviews, and policy review the facility failed to implement their abuse policy to report an allegation of abuse accurately and in a timely manner for Resident #60. The facility also failed to thoroughly investigate an allegation of physical abuse between Resident #3 and #49. This affected three (Resident #3, #49, and #60) out of four residents reviewed for abuse. The facility census was 85.Findings include: 1. Review of the medical record revealed Resident #60 was admitted on [DATE] with diagnoses that included schizoaffective disorder, generalized anxiety disorder, obsessive-compulsive disorder, delusional disorders, and dementia.Review of the self-reported incident (SRI) #267325 dated 11/09/25 revealed an allegation of emotional/verbal abuse by staff towards Resident #60. It was reported Licensed Practical Nurse (LPN) #302 was speaking and behaving in a manner that could be deemed inappropriate. Resident #60 stated a LPN #302 took…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of self-reported incident (SRI), interviews, and policy review the facility failed to report an allegation of abuse immediately and accurately. This affected one (Resident #60) out of four residents reviewed for abuse. The facility census was 85.Findings include:Review of the medical record revealed Resident #60 was admitted on [DATE] with diagnoses that included schizoaffective disorder, generalized anxiety disorder, obsessive-compulsive disorder, delusional disorders, and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. Review of self-reported incident (SRI) #267325 dated 11/09/25 revealed an allegation was made of emotional/verbal abuse by staff towards Resident #60. It was reported Licensed Practical Nurse (LPN) #302 was speaking and behaving in a manner that could be deemed inappropriate. Resident #60 stated a LPN #302 took Resident #60 down the hallway, away from other residents, and spoke with Resident #60 in 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, review of self-reported incident (SRI), interviews, and policy review, the facility failed to thoroughly investigate an allegation of physical abuse between Resident #3 and #49. This affected two (Resident #3 and #49) out of four residents reviewed for abuse. Facility census was 85. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included schizoaffective disorder, type 2 diabetes, psychosis, anxiety, and dementia.A general progress note dated 10/27/25 at 1:53 P.M. revealed Resident #3 appeared agitated over smoking schedule. A new order was received for two milligrams of Ativan (antianxiety) now. A general progress note dated 10/27/25 at 3:23 P.M. revealed Resident #3 appeared calm. There were no outbursts of yelling or any inappropriate behaviors at this time. A general progress note dated 10/28/25 at 4:45 P.M. revealed a new order was received for scheduled Ativan two milligrams every evening for anxiety and aggression.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 medical record review, staff interview, and facility policy review, the facility failed to ensure a requested discharge process was completed timely and thoroughly. This affected two residents (Residents #44 and #82) of three residents reviewed for discharge process. The census was 85.Findings Include:1. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were anoxic brain injury, dementia, bipolar disorder, major depressive disorder, edema, post traumatic stress disorder, opioid use, anxiety disorder, anemia, insomnia, and nightmare disorder. Review of her minimum data set (MDS) assessment, dated 09/30/25, revealed she was cognitively intact.Review of Resident #44 progress notes, dated 09/30/25 to 10/16/25, revealed 13 different referrals were sent to other nursing facilities for the possible transfer/discharge of Resident #44. Documentation supported that she was denied admittance to all of those facilities. After 10/16/25, there was no documentation to support more referrals were sent…

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, review of facility policy, and review of the Ohio Administrative Code, the facility failed to ensure qualified personnel removed a midline intravenous (IV) catheter. This affected two (#22 and #49) of four residents reviewed with midline or peripheral intravenous central catheters (PICC). The facility census was 87. Findings include:Review of the medical record for Resident #22 revealed an admission date of 09/15/25. Diagnoses included urinary tract infection (UTI). Review of the Interim Payment Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact. Resident #22 received intravenous medications within the last fourteen days and had no noted behaviors of refusal of medication. Review of the physician's orders dated 10/10/25 for Resident #22 revealed medication orders including cefazolin sodium injection solution reconstituted (antibiotic) one gram (gm) use one gm intravenously every eight hours for UTI until 10/13/25.…

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 staffing reports, review of facility staff time punches and staff interviews, the facility failed to provide eight hours of consecutive Registered Nurse (RN) direct care and had the Regional Director of Nursing as providing resident care for three days reviewed in a seven-day (one week) period. This had the potential to affect all 94 residents living in the facility. Findings include:A review of the facility staffing reports dated 09/04/25, 09/05/25, and 09/10/25 revealed that the facility did not have a Registered Nurse scheduled for eight hours of consecutive direct care on those three dates. Regional Director of Nursing #200 was scheduled to be the Director of Nursing in the building for 09/04/25, 09/05/25, and 09/10/25. A review of the punch report dated 09/04/25 through 09/10/25 revealed that no RN coverage was in place for 09/04/25, 09/05/25, and 09/10/25. An interview with Regional Director of Nursing #200 on 09/16/25 at 2:03 P.M. revealed that she was in the facility on 09/04/25, 09/05/25, and 09/10/25 providing resident care. An interview 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.

Based on record review, review of the facility assessment, review of the Administrator Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected four (#32, #51, #79, #81) of 17 sampled residents with the potential to affect all 94 residents residing in the facility. Findings include:During the survey, the following care concerns were identified by the survey team. The facility's inaction caused serious harm and had the likelihood of causing serious harm or injury to all residents:1. Based on observation, record review, review of a facility timeline of events, review of hospital records and a physician after visit summary, facility policy review and interview, the facility failed to prevent an incident of neglect involving Resident #32. This resulted in Immediate Jeopardy and Actual Harm beginning on 09/19/25 at 10:30 A.M. when Resident #32, who was identified to have…

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 quality assurance/performance improvement (QAPI) minutes, review of the governing body, interviews, and policy review the facility failed to have an effective governing body to oversee the functions of the facility. This affected four (#32, #51, #79, #81) of 17 sampled residents with the potential to affect all 94 residents residing in the facility. Findings include: Review of the facility Governing Body composition revealed it stated the intent of the facility was to establish a governing body that oversees the establishing and implementing of policies and procedures regarding the management and operation of the facility. The governing body for the facility is as follows:Administrator #188; Director of Nursing #303; Medical Director #301; Regional Director of Clinical Services #201; Regional Director of Operations #350; Director of Corporate Compliance; [NAME] President of Operations #203; and [NAME] President of Clinical Services #300.During the survey, the following care concerns were identified by the survey team related to the facility's failure to have an…

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 Quality Assurance and Performance Improvement (QAPI) minutes, review of policies, and interviews, the facility failed to ensure the medical director implemented resident care policies, coordinated medical care in the facility, and participated in QAPI meetings. This affected three (#40, #79, #95) of 17 residents reviewed during the course of the survey and affected all 94 residents residing in the facility due to the failure of the medical director fulfillment of his responsibilities. Findings include:1.Review of QAPI minutes dated 07/30/25 revealed transportation is experiencing issues with residents getting to appointments who need to go by cot. The transportation contract was suddenly dropped and no backup plan was in place. An action step stated the transportation coordinator and the administrator will reach out to cot transport companies to secure a contract for the facility to ensure residents who need cot transport receive those services. It stated the administrator and transportation aide would meet weekly to discuss progress with a cot transportation…

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 quality assurance/performance improvement (QAPI) minutes, interviews, and policy review the facility failed to have an effective QAPI program. This affected six (#3, #40, #51, #79, #81, #95) and of 17 residents reviewed during the course of the survey and all 94 residents residing in the facility.Findings include: Review of QAPI minutes dated 07/30/25 revealed transportation is experiencing issues with residents getting to appointments who need to go by cot. The transportation contract was suddenly dropped and no backup plan was in place. An action step stated the transportation coordinator and the administrator will reach out to cot transport companies to secure a contract for the facility to ensure residents who need cot transport receive those services. It stated the administrator and transportation aide would meet weekly to discuss progress with a cot transportation contract until the issue is resolved. There was no evidence of weekly meetings by the administrator and transportation aide. There was no list of who attended the meeting. Review of QAPI minutes…

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, observations, and staff interview, the facility failed to ensure resident records were complete and accurately documented. This affected four (#6, #40, #79, and #81) of 17 sampled residents. The facility census was 94. Findings include:1.Review of the medical record for Resident #6 revealed an admission date of 01/18/18 and diagnoses including anxiety disorder, hypertension, and chronic obstructive pulmonary disease. The resident had a physician's order for Ativan (an antianxiety medication) one milligram three times daily at 9:00 A.M., 3:00 P.M., and 9:00 P.M. Review of the medication administration record for September 2025 revealed the Ativan was documented as given on 09/07/25 at 9:00 A.M. However, review of the controlled substance administration record revealed Ativan was not signed out as given on 09/07/25 at 9:00 A.M. Interview with LPN/Unit Manager #241 on 09/17/25 at 2:15 P.M. confirmed the medication was documented as given on the medication administration record but had not been signed out on the controlled substance administration record 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 review of Resident Council Meeting Minutes and staff interview, the facility failed to act promptly upon the grievances concerning issues of resident care voiced by residents at resident council meetings. This affected nine (9) residents who attended the resident council meeting (Residents #7, #24, #49, #72, #74, #76, #80, #85, and #92). The facility census was 94.Findings include: Review of Resident Council Meeting Minutes from 08/13/25 revealed Residents #7, #24, #49, #72, #74, #76, #80, #85, and #92 attended the meeting. Concerns were voiced by unnamed residents regarding not receiving medications timely, staffing, and continuity of care. The page said to see back. However, there was nothing on the back of the form. There were no further specifics given as to what the resident concerns were regarding staffing and continuity of care. There was no evidence of any follow up by the facility to determine specifically what the concerns were. There was no evidence of any action taken by the facility regarding the concerns.Evidence of what the specific concerns were and what…

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, policy review, staff interview, and family interview, the facility failed to notify the resident's representative when there was a significant change in the resident's physical status and when the resident was transferred to the hospital for treatment. This affected one (#32) of 17 sampled residents. The facility census was 94.Findings include:Review of the medical record for Resident #32 revealed an admission date of 07/10/23. The resident was [AGE] years old and had diagnoses including cerebral infarction, glaucoma, vascular dementia, and anxiety disorder.Review of nursing progress notes dated 09/19/25 at 7:45 P.M. revealed Licensed Practical Nurse (LPN) #248 documented Resident #32 was approved to go outside to the courtyard by social service assistant. Resident was noted by staff to be slumped in wheelchair. Staff applied sternal rub with no response noted. Resident was brought into the building and taken to her room. Temperature 107.5 temporal. Ice packs applied to underarms,…

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, record review, review of controlled substance inventory count sheets, review of pharmacy proof of delivery reports, review of written staff statements, staff interview, resident interview, and policy review, the facility failed to prevent the misappropriation of resident property when a resident's narcotic pain medications were diverted and unaccounted for. This affected one (#51) of three residents reviewed for narcotic pain medications. The facility census was 94.Findings include:Review of the record for Resident #51 revealed an admission date of 06/23/25 and diagnoses including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder. Review of a minimum data set assessment completed 07/10/25 revealed a brief interview for mental status score of 13, indicating intact cognition. Review of physician's orders revealed on 07/10/25 Oxycodone (a narcotic pain medication) 15 milligrams every six hours as needed for severe pain (6-10 level) was ordered. Review of a written statement dated 09/03/25 from Licensed Practical Nurse (LPN) #169…

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

Based on record review, staff interview, and policy review, the facility failed to ensure a resident was free from chemical restraints which were not required to treat a resident's medical symptoms. This affected one (#32) of 17 sampled residents. The facility census was 94.Findings include:Review of the medical record for Resident #32 revealed an admission date of 07/10/23 and diagnoses including cerebral infarction, glaucoma, anxiety disorder, and vascular dementia. Review of a Minimum Data Set assessment completed 07/07/25 revealed a brief interview for mental status score of 14, indicating intact cognition. The resident required substantial/maximum assistance from staff with transfers. The resident was able to independently wheel her wheelchair 50 feet. The resident had no routine orders for any type of psychoactive medications. Review of nursing progress notes dated 09/21/25 at 2:01 A.M. by Licensed Practical Nurse (LPN) #169 revealed the resident returned from the hospital after being sent on 09/20/25 for multiple blisters on her arms and legs which were noted after she had…

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

Based on observation, record review, review of self-reported incidents (SRI), and staff interviews, the facility failed to report an allegation of missing narcotics. This affected two (#51, #81) of 17 sampled residents. The facility census was 94.Findings include: Review of the record for Resident #51 revealed an admission date of 06/23/25 and diagnoses including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder. Review of a minimum data set assessment completed 07/10/25 revealed a brief interview for mental status score of 13, indicating intact cognition. Review of physician's orders revealed on 07/10/25 Oxycodone (a narcotic pain medication) 15 milligrams every six hours as needed for severe pain (6-10 level) was ordered. Review of a written statement dated 09/03/25 from Licensed Practical Nurse (LPN) #169 revealed on 08/29/25 LPN #195 reported that she believed Resident #51 had a full card of Oxycodone during her last shift. However, she stated the resident is currently out of medication. The resident is allowed to take one tablet every six hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, staff interviews, policy review, and observation, the facility failed to ensure that residents on the locked unit were protected during the course of an investigation into resident to resident abuse. This affected one (#14) of three residents reviewed for abuse. The facility also failed to thoroughly investigate an allegation of missing narcotics. This affected two (#51, #81) of three residents reviewed for narcotic use. The facility census was 94.Findings include:1.Review of the record for Resident #51 revealed an admission date of 06/23/25 and diagnoses including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder. Review of a minimum data set assessment completed 07/10/25 revealed a brief interview for mental status score of 13, indicating intact cognition. Review of physician's orders revealed on 07/10/25 Oxycodone (a narcotic pain medication) 15 milligrams every six hours as needed for severe pain (6-10 level) was ordered. Review of a written…

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

Based on record review, staff interview, and resident interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This affected one (#51) of three residents reviewed for showers/bathing. The facility census was 94.Findings include:Review of the medical record for Resident #51 revealed an admission date of 06/23/25 and diagnoses including Bipolar disorder, diabetes, chronic kidney disease, and congestive heart failure. Review of the Minimum Data Set assessment completed 07/10/25 revealed a brief interview for mental status (BIMS) score of 13, indicating intact cognition. It further indicated the resident was always incontinent of bowel and bladder, was dependent for toileting, and required substantial/maximal assistance with bathing.Interview with Resident #51 on 09/16/25 at 1:05 P.M. revealed she normally only gets one shower per week and that is when she asks for it. She stated she would prefer two per week.Review of shower sheets for the past month…

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

Based on record review, staff interview, and contract review, the facility failed to ensure ongoing communication and collaboration with a dialysis facility regarding dialysis care and services for a resident. This affected one (#40) of 17 sampled residents. The facility census was 94.Findings include:Review of the record for Resident #40 revealed an admission date of 07/10/25 and diagnoses including diabetes, end stage renal disease, and left leg below the knee amputation. Review of a Minimum Data Set assessment completed 08/08/25 revealed a brief interview for mental status of 15, indicating intact cognition.Record review revealed Resident #40 went to an outside dialysis facility three times weekly for hemodialysis. Review of nursing progress notes revealed on 07/25/25 at 5:26 P.M. it was documented that the resident had a critically low hemoglobin of 6.9 grams per deciliter (g/dL) (normal 14-18). (Hemoglobin is a protein in red blood cells that carries oxygen throughout the body). It was documented that the nurse practitioner was notified and a new order was given. A blood test…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and staff interviews, the facility failed to implement appropriate behavioral healthcare and interventions for a resident's behaviors. This affected one (#14) resident of three residents reviewed for behavioral services. The facility census was 94.Findings include:Review of the medical record for Resident #14 revealed an admission date of 02/17/25 with diagnoses that included Anoxic brain damage, dementia, bipolar disorder, major depressive disorder, hepatitis C, edema, post-traumatic stress disorder (PTSD), attention deficit disorder, opioid use, anxiety disorder, iron deficiency anemia, vitamin deficiency, female pelvic inflammatory disease, psychoactive substance abuse, insomnia, dementia, and nightmare disorder.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #14 required setup for eating and oral hygiene, supervision for most daily activities 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 record review, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#3, #40) of 17 sampled residents. The facility census was 94.Findings include: 1.Review of the medical record for Resident #3 revealed an admission date of 08/16/23 and diagnoses including multiple sclerosis, anxiety disorder, and legal blindness. Review of physician's orders revealed Ativan (antianxiety medication) 0.5 milligrams was decreased from two tablets to one tablet at bedtime on 07/21/25. Review of medication administration records for August and September 2025 revealed nurses were documenting Ativan 0.5 milligrams one tablet at bedtime was given. However, review of controlled substance administration records revealed that on 08/21/25, 08/29/25, 08/30/25, 09/02/25, 09/04/25, and 09/06/25 Ativan 0.5 milligrams two tablets were signed out for Resident #3, indicating he received a double dose of Ativan on those days. The medication label on the controlled substance administration record still indicated to give two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, policy review, and interview, the facility failed to notify physician and family of abnormal radiology results. This affected one resident (#14) of three residents reviewed for notification. The facility census was 89.Findings Include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and other toxic encephalopathy.Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #14's cognition remained intact, and she had no behaviors.Review of nursing notes from 07/25/25 through 07/27/25 revealed no documented evidence of Resident #14 having a fall or being lowered to the ground.Review of a staff statement dated 07/27/25 by certified nurse aide (CNA) #140 revealed after Resident #14 finished using the bathroom, she stood up but was having trouble standing from the low toilet. CNA #140 helped Resident #14 up and the resident was standing very well while her pants…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, policy review and interview, the facility failed to provide timely diagnostic services and treatment when Resident #14 complained of pain to her ankle after a fall. This affected one resident (#14) of three residents reviewed for change in condition. The facility census was 89. Findings include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and other toxic encephalopathy. The resident was discharged from the facility on 08/01/25. Review of a care plan dated 07/14/25 revealed Resident #14 was at risk for falls, goals included to be free of minor injuries and major injuries during her stay. Interventions included but were not limited to anticipate and meet resident's needs, call light in reach, education on safety reminders and what to do if a fall occurs, ensure proper footwear, and therapy as needed.Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, non-facility staff interview, and facility policy review, the facility failed to ensure accurate/clear advanced directives were in place at the time of a resident's death. This affected one, (Resident #90), of three resident reviewed for advanced directives. The census was 88. Findings Include: Resident #90 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, waldenstrom macroglobulinemia, atrial fibrillation, dementia, dysphagia, schizophrenia, hypertension, anemia, catatonic disorder, restlessness and agitation, encounter for palliative care, hallucinations, psychosis, and colostomy status. Review of his minimum data set (MDS) assessment, dated [DATE], revealed he had a severe cognitive impairment. Review of Resident #90's physician orders found he was placed on hospice services on [DATE]. Review of Resident #90's medical records, dated [DATE] to [DATE], revealed no hospice records. There was no hospice documentation on site, including 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, non-facility staff interview, and facility policy review, the facility failed to ensure all resident medical records were complete. This affected one (Resident #90) of three resident medical records reviewed. The census was 88. Findings Include: Resident #90 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, waldenstrom macroglobulinemia, atrial fibrillation, dementia, dysphagia, schizophrenia, hypertension, anemia, catatonic disorder, restlessness and agitation, encounter for palliative care, hallucinations, psychosis, and colostomy status. Review of his minimum data set (MDS) assessment, dated [DATE], revealed he had a severe cognitive impairment. Review of Resident #90 progress notes, dated [DATE], revealed two notes that stated, expired and body released to funeral home. There was no documentation in any portion of his medical record to explain how he expired, what happened prior to his expiration, and what was done (if anything) 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 and staff interview, the facility failed to ensure hospice records were in the facility for full access and review. This affected one, (Resident #90), of one resident reviewed for hospice services. The census was 88. Findings Include: Resident #90 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, waldenstrom macroglobulinemia, atrial fibrillation, dementia, dysphagia, schizophrenia, hypertension, anemia, catatonic disorder, restlessness and agitation, encounter for palliative care, hallucinations, psychosis, and colostomy status. Review of his minimum data set (MDS) assessment, dated 04/22/25, revealed he had a severe cognitive impairment. Review of Resident #90's physician orders found he was placed on hospice services on 05/01/25. Review of Resident #90's medical records, dated 05/01/25 to 05/10/25, revealed no hospice records were included in the record. There was no hospice documentation on site, including no hospice plan of care, no hospice progress…

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 care plan and document on Resident #43's behaviors and ensure the physician or Certified Nurse Practitioner (CNP) addressed his behaviors. This affected one resident (#43) of four residents reviewed for abuse. The facility census was 90. Findings includes: Review of Resident #43's medical record revealed an admission date of 01/02/25 with diagnoses including chronic obstructive pulmonary disease, chronic heart failure, bipolar disorder, and presbyopia. Review of Resident #43's physician order dated 04/01/25 to 05/16/25 revealed an order for 15-minute checks. Review of Resident #43's progress notes dated 04/01/25 at 3:41 A.M. revealed Resident #43 was accused of sexual behaviors. Social Service Director (SSD) #168 revealed they met to discuss allegations, which Resident #43 denied. He was also educated on not entering female's rooms while they are naked. Review of Resident #43's progress note dated 04/06/25 at 3:05 P.M. revealed Resident #43 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the Ohio Department of Health (ODH) Gateway and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse to the state agency. This affected two residents (#26 and #70) of four residents reviewed for sexual abuse. The facility census was 91. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 01/02/25 with diagnoses including chronic obstructive pulmonary disorder, congestive heart failure, benign prostrate hypertrophy and bipolar disorder. Resident #26 was his own person with no designated power of attorney (POA). Review of the plan of care initiated on 03/24/25 revealed Resident #26 had a behavior problem as evidenced by making sexually inappropriate comments to the staff. The goal stated Resident #26 would have fewer episodes by the review date. The interventions included administering medications as ordered, anticipating and meeting resident needs, caregivers to provide…

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 thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected two residents (#26 and #70) of four residents reviewed for sexual abuse. The facility census was 91. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 01/02/25 with diagnoses including chronic obstructive pulmonary disorder, congestive heart failure, benign prostrate hypertrophy and bipolar disorder. Resident #26 was his own person with no designated power of attorney (POA). Review of the plan of care initiated on 03/24/25 revealed Resident #26 had a behavior problem as evidenced by making sexually inappropriate comments to the staff. The goal stated Resident #26 would have fewer episodes by the review date. The interventions included administering medications as ordered, anticipating and meeting resident needs, caregivers to provide opportunity for positive interaction, and attention,…

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, review of a self-reported incident (SRI), facility policy review, and interview, the facility failed to accurately and timely identify and address sexually oriented behaviors involving cognitively impaired residents (#71 and #32) to ensure the residents were able to consent to sexual activity and to prevent potential incidents of resident to resident sexual abuse. This affected two residents (#71 and #32) of four residents reviewed for sexual abuse. The facility census was 91. Findings include: Review of Resident #71's medical record revealed an admission date of 12/23/24 with diagnoses including atrial fibrillation, diabetes mellitus type two, morbid obesity, unspecified mood disorder, depression, and dementia. Record review revealed Resident #71 was her own person with no designated power of attorney (POA). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of four indicating 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 medical record review, interview, and facility policy review, the facility failed to ensure three residents (#9, #68, and #79) were seen by a physician as required every 30 days for the first 90 days then every sixty thereafter. This affected three of 23 sampled residents. Findings Include: 1. Review of the medical record for Resident #68 revealed an initial admission date of 07/12/23 with the diagnoses including chronic obstructive pulmonary disease (COPD), asthma, severe morbid obesity, cerebrovascular accident (CVA) with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal disorder, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anxiety disorder, diabetes mellitus, anemia, nicotine dependence, cardiac arrhythmia and pain in limb. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the medical record revealed Resident #68 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, observation, and interviews, the facility failed to ensure enhanced barrier precautions were in place for residents with indwelling medical devices. This affected one resident (#59) of three residents reviewed for infection control. Additionally, the facility failed to ensure vaccination consents were fully completed, affecting two residents (#9 and #59) of five residents reviewed for vaccinations; and the facility failed to track infectious organisms. This had the potential to affect all 77 residents residing in the facility. The census was 77. Findings include: 1. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pneumonia, respiratory failure with hypoxia, and anorexia. Review of an admission minimum data set completed on 05/30/24 revealed Resident #59's cognition was intact. Review of an undated Patient Vaccination Informed Consent/Declination Form revealed Resident #59 declined to receive the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to ensure residents were treated with dignity and clothed per their preference. This affected one resident (#59) of two residents reviewed for dignity. The facility census was 77. Findings include: Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pneumonia, respiratory failure with hypoxia, and anorexia. Review of a care plan dated 05/22/24 revealed Resident #59 had an activity of daily living (ADL) self-care performance deficit and interventions included allowing sufficient time for dressing and undressing, needs maximum assistance with upper extremity dressing and dependent assistance for lower extremity dressing and putting on or taking off footwear. Review of a Personal Belonging Inventory assessment completed on 05/22/24 at 6:51 A.M. revealed Resident #59 had one shirt, one pair of pants, colostomy equipment, two cell phones and a cell phone…

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 residents (#68) was able to utilize her power wheelchair. This affected one of two residents reviewed for dignity. Findings Include: 1. Review of the medical record for Resident #68 revealed an initial admission date of 07/12/23 with the diagnoses including chronic obstructive pulmonary disease (COPD), asthma, severe morbid obesity, cerebrovascular accident (CVA) with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal disorder, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anxiety disorder, diabetes mellitus, anemia, nicotine dependence, cardiac arrhythmia and pain in limb. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had functional limitations in range of motion to one side of the upper and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure a physician, resident, or the resident's guardian were notified of changes in services and treatment. This affected one resident (#9) of one resident reviewed for hospice services. The facility census was 77. Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, unspecified psychosis not due to a substance or known physiological condition, hypertension, anemia, hyperlipidemia, schizoaffective disorder, major depression, adult failure to thrive, insomnia, and diverticulosis of large intestine without perforation or abscess without bleeding. An additional diagnosis of unspecified severe protein-calorie malnutrition was added on 09/13/21. Review of a care conference sheet dated 01/04/24 revealed Resident #9, her guardian via phone, Activities Director, Social Services Director, Dietary Manager, and another…

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 interviews, the facility failed to follow up on one resident's (#68) report of missing personal items. This affected one of one resident reviewed for personal property. Findings Include: Review of the medical record for Resident #68 revealed an initial admission date of 07/12/23 with the diagnoses including chronic obstructive pulmonary disease (COPD), asthma, severe morbid obesity, cerebrovascular accident (CVA) with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal disorder, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anxiety disorder, diabetes mellitus, anemia, nicotine dependence, cardiac arrhythmia and pain in limb. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. On 06/24/24 at 1:04 P.M., interview with Resident #68 revealed she had an engagement ring and wedding band stolen from her drawer, Resident #68…

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 two residents, who were dependent on staff, were provided shaving of facial hair and nail care. This affected two residents (#59 and #62) of five residents reviewed for activities of daily living (ADL). Findings Include: 1. Review of the medical record for Resident #62 revealed an initial admission date of cerebrovascular accident with right sided hemiplegia, aphasia, dysphagia, diabetes mellitus, protein calorie malnutrition, congestive heart failure, anemia, obstructive and reflux uropathy, hyperlipidemia, major depressive disorder, hypertension, insomnia, chronic pain syndrome, dry eye syndrome and gastro-esophageal reflux disease. Review of the plan of care dated 04/08/24 revealed the resident was at risk for declines/fluctuations in activities of living (ADL) related to present condition, CVA with hemiplegia, aphasia, dysphagia, congestive heart failure, noted limitations to one upper and lower extremity,…

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 and interview, the facility failed to implement a treatment to and monitor an abrasion behind Resident #79's right ear. This affected one of one resident (#79) reviewed for skin conditions. Findings Include: Review of the medical record for Resident #79 revealed an initial admission date of 01/23/24 with the diagnoses including but not limited to chronic obstructive respiratory failure (COPD), acute and chronic respiratory failure with hypoxia, severe protein calorie malnutrition, emphysema, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, hyperlipidemia, bipolar disorder, sleep disorder, mood disorder, suicidal ideations, poisoning by drugs, medicaments and biological substances intentional self harm, nicotine dependence, palliative care and overactive bladder. Review of the incident report dated 05/17/24 at 1:10 P.M. revealed the nurse was notified the resident was outside in her wheelchair and fell forward out of her wheelchair. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure residents had physician orders for safety/fall interventions including the use of a perimeter mattress. This affected one resident (#38), of the five residents reviewed for fall interventions. Findings include: Review of the medical record for Resident #38 revealed an admission date of 01/18/18. Diagnoses included chronic obstructive pulmonary disease, primary generalized osteoarthritis, chronic pain, and alcohol inducted persisting dementia. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision making abilities. Noted to be free from any bilateral upper or lower extremity impairment and required the use of a wheelchair for mobility. Resident #38 required partial to moderate assistance for bed mobility and substantial to maximal assistance for transfers.…

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 and interview, the facility failed to implement a physician ordered dressing change to bilateral nephrostomy tubes (a tube that drains urine from your kidney into a bag) upon readmission to the facility. This affected one resident (#27) of two residents reviewed urinary tract infection. Findings Included: Review of the medical record for Resident #27 revealed an initial admission date of 03/12/22 with the latest readmission of 06/20/24 with diagnoses including congestive heart failure, acute and chronic respiratory failure with hypoxia, diabetes mellitus, chronic obstructive pulmonary disease, (COPD), severe morbid obesity, hyperlipidemia, hypertension, obstructive sleep apnea, lymphedema, major depressive disorder, gastro-esophageal reflux disease, constipation, bacteremia, urinary tract infection, disorder of kidney and ureter, anemia, chronic kidney disease, stage three, artificial openings of urinary tract status, presence of urogenital implants, hydronephrosis with renal…

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 interview, the facility failed to ensure resident's received medically-related social services to maintain the highest practicable psychosocial well-being. This affected one resident (#9) of one resident reviewed for receiving social services. The facility census was 77. Findings include: Record review revealed Resident #9 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, unspecified psychosis not due to a substance or known physiological condition, hypertension, anemia, hyperlipidemia, schizoaffective disorder, major depression, adult failure to thrive, insomnia, and diverticulosis of large intestine without perforation or abscess without bleeding. An additional diagnosis of unspecified severe protein-calorie malnutrition was added on 09/13/21. Review of a care conference sheet dated 01/04/24 revealed Resident #9, her guardian via phone, Activities Director, Social Services Director, Dietary Manager, and another…

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 interview, the facility failed to ensure as needed pain medication had parameters in place. This affected one resident (#59) of two residents reviewed for pain. The facility census was 77. Findings include: Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pneumonia, respiratory failure with hypoxia, and anorexia. Review of orders revealed Resident #59 had an order in place starting on 05/22/24 for Acetaminophen oral tablet 325 milligrams (mg) give two tablets by mouth every six hours as needed for mild pain. The resident had an order starting on 06/26/24 for oxycodone oral tablet 15 mg give one tablet by mouth every eight hours as needed for pain. The resident had an order starting on 06/27/24 for oxycodone oral tablet five mg give three tablets by mouth every eight hours as needed for pain. There were no parameters for pain medication administration. Review of an admission minimum data set…

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 interview, the facility failed to ensure medications were stored in a locked compartment. This affected one resident (#1) of 77 residents in the facility. Findings Include: On 06/27/24 at 2:28 P.M., during a search of Resident #1's room for her right wrist brace, a clear plastic cup of pudding was found with chunks of a crushed white pill in them by State Tested Nursing Assistant (STNA) #116 on top of Resident #1's dresser. On 06/27/24 at 2:43 P.M., interview with Registered Nurse (RN) #223 revealed Resident #1's medications are administered whole and not crushed. RN #223 revealed she was unsure where the cup of medication came from and what the medication was. On 06/27/24 at 2:55 P.M., interview with Licensed Practical Nurse (LPN) #111 verified the white chunks in the clear plastic cup containing pudding was a white pill (narcotic) and was not stored in a locked compartment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure accurate and complete medical records in the area of nutritional supplement intake. This affected one resident (#79) of three residents reviewed for weight loss. Findings Include: Review of the medical record for Resident #79 revealed an initial admission date of 01/23/24 with the diagnoses including but not limited to chronic obstructive respiratory failure (COPD), acute and chronic respiratory failure with hypoxia, severe protein calorie malnutrition, emphysema, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, hyperlipidemia, bipolar disorder, sleep disorder, mood disorder, suicidal ideations, poisoning by drugs, medicaments and biological substances intentional self harm, nicotine dependence, palliative care and overactive bladder. Review of the plan of care dated 01/30/24 revealed the resident had nutritional problem or potential nutritional problem related to mechanically altered diet, history 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 record review and interview, the facility failed to ensure a communication process was in place with a hospice company resulting in Resident #9 having a delay in hospice services. This affected one resident (#9) of one resident reviewed for hospice. The facility census was 77. Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, unspecified psychosis not due to a substance or known physiological condition, hypertension, anemia, hyperlipidemia, schizoaffective disorder, major depression, adult failure to thrive, insomnia, and diverticulosis of large intestine without perforation or abscess without bleeding. An additional diagnosis of unspecified severe protein-calorie malnutrition was added on 09/13/21. Review of a care conference sheet dated 01/04/24 revealed Resident #9, her guardian via phone, Activities Director, Social Services Director, Dietary Manager, and another staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents required antibiotics prior to administration of antibiotics. This affected two residents (#237 and #50) of six residents reviewed for antibiotic stewardship. The facility census was 77. Findings include: 1. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including obsessive compulsive disorder, anemia, chronic pain, and gastro-esophageal reflux disease. Review of the infection control log for February 2024 revealed Resident #50 had a urinary tract infection which was treated with Amoxicillin. Review of a McGeer Criteria for Infection Surveillance (dated 02/14/24) revealed to meet criteria for treatment of a UTI criteria one (at least one of the following: acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate; fever or leukocytosis and one or more of the following- acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to notify Resident #61's primary care physician (PCP) of an elopement from the facility. This affected one resident (#61) of three residents for elopement. The facility census was 86. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 03/08/24 with admitting diagnoses including traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, nontraumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), diabetes mellitus, bipolar disorder, cerebral infarction, gastro-esophageal reflux disease (GERD), major depressive disorder, post-traumatic stress disorder, hypertension, seizures, anxiety disorder, atrial fibrillation, anterior displaced fracture of sternal end of clavicle, conversion disorder with motor symptom of deficit, mood disorder, fracture of second thoracic vertebra, multiple fractures of ribs, right side, psychoactive substance…

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 ensure Resident #2, who was dependent on staff for bathing received scheduled showers. This affected one resident (#2) of three residents reviewed for showers. The facility census was 86. Findings Include: Review of the medical record for Resident #2 revealed an initial admission date of 07/12/23 with diagnoses including chronic obstructive pulmonary disease, asthma, severe morbid obesity, cerebrovascular accident with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal reflux disease, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anemia, pain, nicotine dependence and diabetes mellitus. Review of the plan of care dated 07/13/23 revealed the resident was at risk for declines/fluctuations in activities of daily living (ADL) related to poor condition, balance impairment with transfers and able to stabilize with staff assist, non ambulatory at…

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 and interview, the facility failed to ensure Resident #2 was timely and appropriately treated for a urinary tract infection (UTI). This affected one resident (#2) of two residents reviewed for UTI. The facility census was 86. Findings include: Review of the medical record for Resident #2 revealed an initial admission date of 07/12/23 with diagnoses including chronic obstructive pulmonary disease, asthma, severe morbid obesity, cerebrovascular accident with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal reflux disease, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anemia, pain, nicotine dependence and diabetes mellitus. Review of the plan of care dated 07/25/23 revealed the resident was at risk for declines in continence, UTI, red and/or open areas related to present condition, noted to be frequently incontinent of bladder, needs staff assist with toileting and peri-care need 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and facility policy review, the facility failed to ensure narcotic pain medication was available to administer to one resident (#34). This affected one (Resident #34) of three residents reviewed for pain. The facility census was 87. Findings Include: Review of the medical record for Resident #34 revealed an initial admission date of 01/11/24 with diagnoses including malignant neoplasm, of bronchus or lung, secondary malignant neoplasm of brain, secondary malignant neoplasm of liver, protein calorie malnutrition, diabetes mellitus, chronic obstructive pulmonary disease (COPD), centrilobular emphysema, atrial fibrillation, seizures, hyperlipidemia, hypertension, sick sinus syndrome, lesion of sciatic nerve left lower limb, neoplasm related pain, major depressive disorder, overactive bladder, secondary malignant neoplasm of bone, tremors, adult failure to thrive, antineoplastic chemotherapy and antineoplastic immunotherapy. Review of the plan of care dated 01/14/24 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of witness statements and staff interview, the facility failed to thoroughly investigate Former Registered Nurse (RN) #122 working while suspected of being under the influence of alcohol in order to ensure the residents Former RN #122 was assigned to care for were not adversely affected or subject to any type of abuse, neglect or misappropriation as a result of the incident. This had the potential to affect all 22 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #36, #38, #40, #42, #45, #83) residing on Unit A and the even rooms in Unit C. The facility census was 78. Findings include: Review of the witness statement by RN #131, dated 10/15/23, revealed staff on Unit A brought a cup to the writer (RN #131) stating Former RN #122 had vodka or some alcohol in a water bottle. Upon smelling the cup, it was noted to have a strong alcoholic odor. Staff reported erratic behavior from the nurse (Former RN #122). RN #131 and another nurse approached Former RN #122 and…

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

Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents were bathed according to their preference. This affected one (Resident #2) out of the three residents reviewed for bathing. The facility census was 78 Findings include: Review of the medical record for Resident #2 revealed an admission date of 07/12/23. Resident #2's diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, difficulty on feet, and difficulty walking. Resident #2 was her own representative and responsible party. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/23, revealed Resident #2 had intact cognition. Resident #2 was dependent on staff for bathing and showering needs. Review of Resident #2's shower schedule revealed Resident #2 was scheduled to receive a bath or shower on Tuesday's and Thursday's during day shift. Review of Resident #2's provided bath and showers listed under the completed activities of daily living (ADL) task from 09/01/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview and policy review, the facility failed to ensure shared glucometers (device used to determine a resident's blood glucose level by placing a drop of blood on a test strip and inserted into the glucose meter) were properly disinfected between uses. This affected four residents (Residents #6, #22, #25, and #32). Findings include: A review of Resident #32's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult inset diabetes mellitus. A review of Resident #32's physician's orders revealed she had an order to receive Novolog insulin twice a day per sliding scale based on the resident's blood glucose level. Her coverage for the sliding scale Novolog insulin began at 151 milligrams/ deciliter (mg/dl). On 04/20/22 at 8:00 A.M., an observation of a medication administration pass to Resident #32 noted Licensed Practical Nurse (LPN) #110 to check the resident's blood glucose level using a glucometer. She obtained the glucometer…

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

Based on observation and staff interview the facility failed to have a working call system from resident toilet rooms on the second floor. This had the potential to affect 30 of 30 residents who lived on the second floor (Resident #34, Resident #47, Resident #3, Resident #29, Resident #38, Resident #43, Resident #54, Resident #46, Resident #132, Resident #65, Resident #15, Resident #8, Resident #33, Resident #39, Resident #40, Resident #24, Resident #2, Resident #80, Resident #12, Resident #48, Resident #42, Resident #23, Resident #285, Resident #44, Resident #286, Resident #36, Resident #37, Resident #35, Resident #57, and Resident #66) of 86 residents who lived in the facility. Findings include: Observation on 04/19/2022 at 8:39 A.M. revealed when the call light in Resident #65's and Resident #29's toilet rooms was activated the light did not illuminate in the hall. The call light panel at the nurses' station did not stay illuminated, there was an audible sound. Interview of Maintenance Director #62 on 04/19/2022 at 9:00 A.M. revealed the call system was old. He confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of state/federal economic stimulus information and Medicaid guidelines, resident medical record review, financial record review, staff interview, and facility policy review, the facility failed to ensure resident financial accounts were maintained within the appropriate limits. This affected three (Residents #11, #41 and #44) of six resident financial records reviewed. The census was 86. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident that utilizes Medicaid insurance may not keep more than $2000 in a trust account. Also, the same guidelines confirmed that the COVID-19 stimulus checks (three total) do not count as monthly income; so it would not affect a resident's medical coverage. But, a resident who utilizes Medicaid insurance, and received stimulus payment(s), they have 12 months to spend that money from the time they receive it. Review of federal COVID-19 stimulus documentation revealed three different economic impact payments made to…

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

Based on review of beneficiary notice documents and staff interview the facility failed to provide all the required notices to residents discharged from skilled nursing services, had not exhausted their benefits, and remained in the facility. This affected two (Resident #44, and Resident #59) of three sampled residents reviewed for beneficiary protection notification. The facility census was 86. Findings include: 1. Review of Resident #44's beneficiary notice documentation revealed he was notified on 02/14/2022 of his discharged from skilled nursing services on 02/16/2022. Resident #44 had not exhausted his skilled nursing benefit and remained in the facility. Resident #44 was issued the Notice of Medicare Non-Coverage (NMNC) but was not issued the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) as required. Interview of Community Relations #46 on 04/21/22 at 12:48 P.M. confirmed Resident #44 was not provided SNFABN, only the NMNC. 2. Review of Resident #59's beneficiary notice documentation revealed he was notified on 04/06/2022 of his discharged from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide the following information to the receiving entity; contact information of the practitioner responsible for the resident's care, contact information of the resident's representative, comprehensive care plan goals, and a discharge summary. This affected two residents (Resident #65 and Resident #82) of two sampled residents reviewed for facility initiated transfers. The facility census was 86. Findings include: 1. Review of Resident #65's medical record revealed he was admitted on [DATE] with diagnoses that included: paroxysmal atrial fibrillation, chronic kidney disease, type II diabetes, dementia with behavioral disturbance, hyperlipidemia, major depressive disorder, and schizoaffective disorder. Review of Resident #65's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #65's speech was clear, he made himself understood, understands others, and severely impaired decision making. Resident #65…

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 notify the resident's representative in writing of discharge and the move and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. In addition, the resident's representative was not provided the reason for the discharge, the location of the discharge, the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman and for residents with mental disorders or related disability the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with mental disabilities. This affected two residents (Resident #65 and Resident #82) of two sampled residents reviewed for facility initiated discharge. The facility census was 86. Findings include 1. Review of Resident #65's medical record revealed he was admitted on [DATE] with diagnoses that included: paroxysmal atrial fibrillation, chronic kidney disease, type II…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, staff interview and policy review, the facility failed to notify the resident or the resident's representative of the duration of the state bed hold policy and the facility's policies regarding bed-hold periods. This affected two residents (Resident #65 and Resident #82) of two sampled residents reviewed for discharge. The facility census was 86. Findings include: 1. Review of Resident #65's medical record revealed he was admitted on [DATE] with diagnoses that included: paroxysmal atrial fibrillation, chronic kidney disease, type II diabetes, dementia with behavioral disturbance, hyperlipidemia, major depressive disorder, and schizoaffective disorder. Review of Resident #65's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #65's speech was clear, he made himself understood, understands others, and severely impaired decision making. Resident # 65 had no indicators or psychosis, had verbal behaviors four to six days: that placed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure comprehensive resident assessments were conducted every 12 months. This affected one resident (Resident #29) of 19 sampled residents whose comprehensive assessments were reviewed. The facility census was 86. Findings include: Review of Resident #29's medical record revealed she was admitted on [DATE] with diagnoses that included: schizoaffective disorder bipolar type, personality disorder, catatonic disorder, anxiety disorder, and dystonia. Review of Resident #29's record revealed an annual Minimum Data Set (MDS) assessment dated [DATE]. An annual MDS dated [DATE] was in the process of completion. Interview of Registered Nurse (RN) on 04/19/22 at 3:16 P.M. confirmed Resident #29's MDS was conducted annually and was late.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) Identification Screen was completed for residents who had a newly added serious mental illness diagnosis. This affected two (Resident #25 and #65) of six residents reviewed for PASARR). Findings include: 1. A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included major depressive disorder. A newly added diagnosis of schizo-affective disorder, bipolar type was added on 02/03/21. A PASARR identification screen dated 01/19/16 revealed Resident #25's PASARR was completed as he was seeking admission to the nursing facility. Section (D.) of the PASARR documented any indications of a serious mental Illness. The only relevant diagnoses the resident was indicated to have was a mood disorder and depression. A preadmission screen (PAS) determination, as a result of that PASARR, revealed the PAS determination was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to notify the state mental health authority promptly after residents had a significant change in their mental condition/ newly added diagnosis of a serious mental illness. This affected two (Resident #25 and #65) of six residents reviewed for Preadmission Screening and Resident Review (PASARR). Findings include: 1. A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included major depressive disorder. A newly added diagnosis of schizo-affective disorder, bipolar type was added on 02/03/21. A PASARR identification screen dated 01/19/16 revealed Resident #25's PASARR was completed as he was seeking admission to the nursing facility. Section (D.) of the PASARR documented any indications of a serious mental Illness. The only relevant diagnoses the resident was indicated to have was a mood disorder and depression. A preadmission screen (PAS) determination, as a result of that PASARR,…

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, policy review, and staff interview, the facility failed to complete a recapitulation of an anticipated discharge of a resident. This affected one resident (Resident #84) of one sampled resident reviewed for an anticipated discharge. The facility census was 86. Findings include: Review of Resident #84's medical record revealed she was admitted on [DATE] and discharged on 02/21/2022 with diagnoses that included: respiratory failure, atrial fibrillation, pulmonary hypertension, morbid obesity, and history of COVID-19. Review of Resident #84's discharge planning assessment dated [DATE] revealed Resident #84 was admitted for short term stay, with the expectation of returning to the community, and plans to live with care giver. Resident #84 was discharged [DATE] and there was no recapitulation of Residents #84's stay. Interview of Licensed Practical Nurse (LPN) #65 on 04/21/22 at 2:51 P.M. confirmed Resident #84 was an anticipated discharge, and no recapitulation of Resident #84's stay…

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, staff interview and facility policy review, the facility failed to ensure one resident (#5), who was dependent on staff received nail care. This affected one of three residents reviewed for activities of daily living (ADL). Findings Included: Review of Resident #5's medical record revealed an admission date of 01/22/16 with the admitting diagnoses of Parkinson's disease, rheumatoid arthritis, diabetes mellitus, hypertension, hyperlipidemia, psychosis, major depressive disorder, overactive bladder, mood disorder, anxiety disorder, dry eye syndrome, vitamin B deficiency, niacin deficiency, Vitamin D deficiency, thiamine deficiency, constipation, pain, restless leg syndrome, insomnia and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, makes himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure one resident (#21) vascular wounds were initially assessed and subsequently assessed weekly. This affected one of three residents reviewed for skin conditions. Findings Include: Review of Resident #21's medical record revealed an initial admission date of 10/25/19 with the latest readmission of 02/23/22. Diagnoses included chronic obstructive pulmonary disease (COPD), atrial fibrillation, asthma, hypertension, congestive heart failure, severe morbid obesity, obstructive sleep apnea, osteoarthritis, shared psychotic disorder, major depressive disorder, hypothyroidism and history of COVID-19. Review of the nursing admit/readmit date d 02/23/22 revealed the vascular wounds were not present on admission. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a BIMS score of 13. The 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 record review, review of consultation reports from a wound consultant, staff interview and policy review, the facility failed to assess a resident's pressure ulcers weekly to monitor the progression of the wound healing. This affected one (Resident #64) of two residents reviewed for pressure ulcers. Findings include: A review of Resident #64's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included an unstageable pressure ulcer (known but not stageable due to coverage of the wound bed by slough and/ or eschar) of the left buttock, a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough) of the right buttock and a Stage II pressure ulcer of the sacrum. All pressure ulcers were present upon the resident's admission into the facility. A review of Resident #64's nursing admission assessment dated [DATE] confirmed the resident was known to have pressure ulcers to her bilateral buttocks,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to adequately monitor significant weight loss and meal intakes. This affected one (Resident #72) of four residents reviewed for nutrition. The census was 86. Findings Include: Record review revealed Resident #72 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, chronic obstructive pulmonary disease, acute and chronic respiratory failure, acute embolism and thrombosis, asthma, morbid obesity, single subsegmental pulmonary embolism, anemia, hypertension, atrial fibrillation, tremor, sleep apnea, and encephalopathy. Review of her Minimum Data Set (MDS) 3.0 assessment, dated 04/02/22, she was deemed to be cognitively intact. Review of Resident #72 medical records revealed the following weights: 01/22/22 (225.9 pounds), 02/11/22 (220.4 pounds), 02/17/22 (198.6 pounds), and 03/02/22 (198.2 pounds). Review of Resident #72's nutritional note revealed on 02/23/22, the dietitian recognized a significant…

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, and staff interview the facility failed to provide medically related social services to assist a resident in identifying alternative housing options and assistance with legal issues. This affected one resident (Resident #29) of three sampled residents reviewed for discharge. The facility census was 86. Findings include: Review of Resident #29's medical record revealed she was admitted on [DATE] with diagnoses that included: schizoaffective disorder bipolar type, personality disorder, catatonic disorder, anxiety disorder, and dystonia. Resident #29 is her own person and did not have legal oversight. Review of Resident #29's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #29's speech was clear, she made herself understood, understands others, and cognition was moderately impaired. Resident #29 had no behaviors, did not reject care, and did not wander. Resident #29 required supervision with set up help for bed mobility, to transfer, 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 record review, staff interview and policy review, the facility failed to ensure pharmacy recommendations were responded to timely by the physician and the physician provided an appropriate rationale as to why the pharmacy recommendation was contraindicated. This affected three (Resident #5, #16 and #65) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #16's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included polyneuropathy, Bipolar disorder, and opioid dependence. A review of Resident #16's physician's orders revealed she had an order in place for the use of Tizanidine HCL 4 milligrams (mg) by mouth every night at bedtime for spasticity. The order had been in place since 09/11/21. A review of Resident #16's monthly medication regimen reviews for the past 12 months revealed the facility's consulting pharmacist reviewed the resident's medications in January 2022 and a recommendation was made. The Consultant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to provide adequate justification for the use of psychotropic medications. This affected two (Residents #285 and #5) of five residents reviewed for unnecessary medications. In addition, the facility failed to adequately address the use of as needed medications. This affected one (Resident #65) of five residents reviewed for unnecessary medications. The census was 86. Findings Include: 1. Record review revealed Resident #285 was admitted to the facility on [DATE]. His diagnoses were encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, acute and chronic respiratory failure, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, tobacco use, unspecified dementia with behavioral disturbance. His cognitive assessment had not been completed. Review of Resident #285 medical records revealed he had the following medications prescribed and administered since admissions:…

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, review of the manufacturer's product information, staff interview, and policy review, the facility failed to ensure their medication error rate was less than 5%. The facility had two errors out of 25 opportunities for errors for a medication error rate of 8%. This affected two (Resident #32 and #284) of four residents observed for medication administration observation. Findings include: 1. A review of Resident #32's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus. A review of Resident #32's physician's orders revealed she had an order in place to receive Insulin Aspart (Novolog) subcutaneously twice a day per sliding scale. The resident was to begin receiving the sliding scale with a blood sugar result of 151 milligrams/ deciliter (mg/dl) or higher. The sliding scale directed the resident to be given two units of Novolog for a blood sugar between 151 to 200 mg/dl. The order had been in place since…

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 laboratory tests were completed as ordered by the physician. This affected one (Resident #16) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #16's medical record revealed the resident was admitted on [DATE]. Her diagnoses included hypertension, generalized edema, and viral Hepatitis C. A review of Resident #16's physician's orders revealed she was to have a complete blood count (CBC), basic metabolic panel (BMP), lipid profile, and Vitamin D level every three months in the months of March, June, September, and December. The labs were to be drawn on the third Thursday of the month. A review of Resident #16's medical record revealed it was absent for any documented evidence of a CBC, BMP, lipid profile, or Vitamin D level being obtained in March 2022 as ordered. Findings were verified by Licensed Practical Nurse (LPN) #1. On 04/20/22 at 3:55 P.M., an interview with LPN #1 confirmed she was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to ensure justification of antibiotic use for three residents (#14, #48 and #49). This affected three of three reviewed for antibiotic use. Findings Include: 1. Review of Resident #48's medical record revealed an initial admission date of 09/01/18 with the latest readmission of 10/07/18 with the admitting diagnoses of polyarthritis, congestive heart failure, hypertension, hypothyroidism, insomnia and history of COVID-19. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had a severe cognitive deficit as indicated by a BIMS score of three. Review of the December 2021 infection control log revealed an entry 12/13/21 documenting the resident was treated with Macrobid (a medication used to treat an infection) for a urinary tract infection (UTI) consisting of mixed skin flora. Review of the urinalysis and culture…

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 the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the staff vaccination tracker, review of the COVID tracking log, review of staff schedules, review of timecards, review of the facility policy and interviews, the facility failed to implement their policy to ensure the staff COVID-19 vaccination rate was 100%. The facility staff vaccination rate was 96.03%. The census was 86. Findings include: Review of the staff vaccination tracker dated 04/21/22 revealed the facility had a total of 127 employees. There were 93 staff fully vaccinated for COVID-19, 29 staff with a granted exception and five staff partially vaccinated for COVID-19 (State Tested Nursing Assistant (STNA) #11, #57, #66, Activity Aide #22 and Medical Records #25). On 04/21/22 at 3:45 P.M. interview with the Administrator verified the facility had five partially vaccinated…

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.