Park Health Center

2. Review of Resident #70 revealed a 07/29/25 admission with diagnoses including Parkinson's disease, psychotic disorder with delusions, vitamin D deficiency, type 2 diabetes, and anxiety disorder. The admission shower preference sheet dated 07/29/24 indicated a preference for three to four showers a week. Review of the 01/27/25 Quarterly MDS revealed the resident was severely impaired for daily decision making, had hallucinations, delusions, rejection of care, physical and verbal behaviors, He had upper and lower functional impairment on both sides and dependent for bathing. Interview 03/24/25 at 11:47 A.M. with Resident #70's wife revealed the facility was not brushing his teeth, showering and completing dressing changes. He was supposed to be getting showers three times a week and he sometimes doesn't get two a week. They have been better since she brought it to their attention but still doesn't get enough. Review of the shower schedule revealed the resident was a Sunday, Wednesday, and Friday dayshift shower. Review of the Certified Nurse Aide TASK in the electronic record…

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 interview the facility failed to ensure an anticoagulant (Eliquis) medication was administered per orders after the resident received a new diagnoses of pulmonary embolism (blockage of the main artery to the lung or one of its branches). This affected one (Resident #76) of six reviewed for unnecessary medication review. Findings included: Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, heart failure, cerebrovascular disease, and chronic obstructive pulmonary disease. On 03/18/25 pulmonary embolism was added to the diagnosis list. Review of Resident #76's progress note dated 03/16/25 revealed the nurse at the emergency room reported the resident was being admitted for a diagnosis of pulmonary embolism. Review of Resident #76's hospital record dated 03/16/25 revealed the cardiologist was called due to the resident having bilateral pulmonary embolism and potential right heart strain for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of operational manual, review of policy, review of statement, observation and interview the facility failed to ensure low air loss mattress was functioning properly. This affected one (Resident #240) of four residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #240 was admitted to the facility on [DATE] with diagnoses including pressure ulcers, peripheral vascular disease (PVD), metabolic encephalopathy, muscle weakness, anemia, and spondylolisthesis of lumbar region. Review of Resident #240's five-day Minimum Date Set (MDS) dated [DATE] revealed the resident was at risk for pressure and currently had two stage I pressure ulcers (skin intact with non-blanchable erythema) . The resident was substantial/maximal assist with rolling left to right, sit to lying and lying to sitting. Review of Resident #240's pressure ulcer assessment dated [DATE] revealed the resident was at high risk for pressure due to PVD and currently had pressure…

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 care was appropriate for a resident receiving dialysis services. This affected one (Resident #26) of one resident reviewed for dialysis. Findings include: Review of Resident #26 revealed a 06/29/23 admission and readmission [DATE] with diagnoses including morbid severe obesity. chronic atrial fibrillation, dependence on renal dialysis, type 2 diabetes with diabetic neuropathy, chronic peripheral insufficiency, acquired absence of right great toe and other right toes. osteoporosis, hypothyroidism, gastro esophageal reflux disease. lymphedema, anemia, hyperlipidemia, insomnia, absence of other left toes, chronic kidney disease Stage 4 (severe), angina pectoris, hypoxemia, glaucoma and hypertension. Review of the resident's dialysis plan of care initiated 01/18/24 revealed the care plan was generic and did not identify the resident having a fistula. Review of the physician orders included 02/11/25 1200 milliliter (ml) fluid restriction dietary 550…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review the pharmacy failed to ensure medication were available timely for administration. This affected one (Resident #64) of three observed for medication administration, one (Resident #236) of two reviewed for urinary tract infections, and one (Resident #238) of one reviewed for respiratory infection. Findings included: 1. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Review of Resident #64's current orders revealed Ozempic subcutaneous solution pen-injector two milligrams (mg)/1.5 milliliters (ml) subcutaneously one time a day every Wednesday for diabetes. Observation on 03/26/25 at 7:38 A.M., of Resident #64 medication administration with Registered Nurse (RN) #92 revealed the resident Ozempic was not available to administer. The RN confirmed the Ozempic was only administered once a week on Wednesday and the medication should…

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 interview the facility failed to ensure medication were administered per parameters. This affected one (Resident #76) of six reviewed for unnecessary medication review. Findings included: Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, heart failure, cerebrovascular disease, and chronic obstructive pulmonary disease. On 03/18/25 pulmonary embolism was added to the diagnosis list. Review of Resident #76's cardiac plan of care dated 11/19/24 revealed to administer medication as ordered. Review of Resident #76's orders dated 03/2025 revealed the resident was ordered Midodrine 10 milligrams (mg) three times daily (rise, lunch, and bedtime) for hypotension. If the systolic greater than 110 do not give. Review of Resident #76's Medication Administration Record (MAR) dated 03/2025 revealed nurse had administered Midodrine on 03/02/25 at lunch and bedtime when the resident blood pressure was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Center for Disease Control (CDC), review of infection control log, interview, and policy review the facility failed to ensure resident's meet criteria for antibiotics treatment. This affected one (Resident #238) of one reviewed for respiratory infection. Findings included: 1. Medical record review revealed Resident #238 was admitted to the facility on [DATE] with diagnoses including obesity, diabetes, heart disease, and overactive bladder. Review of Resident #238's respiratory care plan dated 03/07/25 revealed diagnostic studies as ordered. Review of Resident #238's progress note dated 03/07/25 revealed the resident stated she had been coughing since yesterday, with worsening today and new symptom of slight dizziness. New order had been obtained for cough syrup and flu swab. Review of Resident #238's laboratory testing dated 03/08/25 revealed Resident #238 tested positive for Influenza A. Review of Resident #238's progress note dated 03/08/25 revealed 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of equipment manufacturer guidelines, policy review and interview, the facility failed to ensure Resident #1 was provided adequate and proper assistance, following manufacturer's guidelines to reposition in a geriatric (geri) chair to prevent an accident with injury. This affected one resident (#1) of three residents reviewed for accidents. The facility identified seven additional residents (Resident #11, #13, #15, #17, #18, #20, and #21) who utilized reclining assistive devices for mobility. The facility census was 71. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of the care plan with an initiation date of 07/14/22, revealed Resident #1 required (staff) assistance…

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 and interview the facility failed to store food properly, check temperatures on cold items prior to serving them, and ensure the oven was clean. This had the potential to affect 72 of 72 residents who received meals from the kitchen. The facility identified four residents, Resident #5, #29, #63, and #68 who received nothing by mouth and did not receive food from the kitchen. The facility census was 76. Findings included: 1. Observation on 10/16/23 at 8:05 A.M. of the facility walk-in refrigerator revealed the following: One large foil pan of cubed potatoes not labeled or dated. A prepared side salad not dated. A two and one half pound bag of salad which had been opened, not dated when opened and it had a best by date of 10/08/23. A one pound bag of shredded lettuce which had been opened, not dated when opened and it had a best by date of 10/14/23. A container of sliced tomatoes not dated. Approximately one third of a tomato in a sandwich size zip lock bag not labeled or dated. Approximately four ounces of pepperoni in a one gallon size zip lock…

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 food was prepared to the ordered consistency. This had the potential to affect five residents (#20, #26, #37,#42, and #130) of five residents who were ordered pureed meals. The facility census was 76. Findings included: On 10/17/23 at 11:30 A.M. Dietary #561 was observed preparing pureed (smooth consistency) chicken cordon bleu. Dietary #561 placed six chicken cordon bleu in the robot coup (industrial blender) and added chicken gravy. Dietary #561 pureed the chicken and after pureeing for approximately 60 seconds, tasted the puree, and reported it was ready to be served. This surveyor then tasted the chicken puree and had to chew pieces of the chicken, not providing a puree consistency. Dietary Manager #525 then tasted the chicken puree and verified she had to chew some. Dietary #561 continued to puree the chicken for an additional 30 seconds before the chicken reached a smooth consistency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, resident record review, facility policy review and review Center for Disease Control (CDC) Guidelines, the facility failed to ensure proper personal protective equipment (PPE) was worn when care was provided to Resident #130 who was diagnosed with COVID-19. This had the potential to affect 39 (Resident #2, #3, #4, #5, #8, #9, #10, #11, #14, #15, #20, #21, #23, #24, #25, #26, #28, #30, #32, #33, #36, #37, #42, #45, #51, #53, #55, #56, #62, #63, #66, #67, #129, #130, #131, #132, #230, #229, and #231) of 39 residents residing on south wing without active COVID-19. The facility census was 76. Findings included: Review of Resident #130's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia, dependence on supplemental oxygen, and chronic obstructive pulmonary disease. Review of Resident #130's physician order, dated 10/14/23, identified she was to be in droplet precautions every shift for COVID until…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a list of psychotropic medications provided by the facility and interview, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were up to date and accurate. This affected two residents (#30 and #37) of two residents reviewed for PASARR. The facility census was 76. Findings include: 1. Review of Resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disordered (entered 02/18/22), bipolar disorder (entered 02/22/22), insomnia (entered 02/22/22), and generalized anxiety disorder (entered 11/08/22). Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/18/23, revealed she was cognitively intact. Further review revealed she had active diagnoses of anxiety disorder, depression, and bipolar disorder. Review of Resident #30's physician order, dated 07/05/23, revealed she was prescribed clonazepam (an antianxiety agent) 0.5 milligrams (mg) to be administered…

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, facility policy review and interview the facility failed to ensure residents' masks and tubing for their noninvasive ventilation were cleaned every morning as ordered and failed to ensure documentation regarding cleaning was accurate. This affected two residents (#9 and #66) of five residents reviewed for respiratory care. The facility census was 76. Findings included: 1. Review of Resident #9's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, type two diabetes, dependence on respirator, atherosclerotic heart disease, and morbid obesity with alveolar hypoventilation. Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/20/23, revealed she was cognitively intact, had an active diagnosis of debility, cardiorespiratory condition, and received oxygen. Review of Resident #9's physician order, dated 07/22/22, identified she was to have her trilogy mask and all tubing…

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 medication orders were followed. This affected one resident (#20) of six residents reviewed for unnecessary medications. The facility census was 76. Findings included: Review of Resident #20's medical record revealed he was admitted to the facility on [DATE] with diagnosis including chronic respiratory failure with hypoxia, essential hypertension, other specified peripheral vascular diseases, shortness of breath, and heart failure. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed he was rarely/never understood and had short-term and long-term memory problems. Further review revealed he had active diagnoses of debility, cardiorespiratory conditions, coronary artery disease, heart failure and hypertension. Review of Resident #20's physician order, dated 09/27/23, identified he was to receive Midodrine HCL (an anti-low blood pressure agent used to raise the blood pressure) oral tablet three times a…

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

Based on record review and interview, the facility failed to ensure hospice visitation notes, assessments and communication were maintained in Resident #16's medical record. This affected one resident (#16) of one resident reviewed for hospice services. The facility census was 76. Findings include: Review of Resident #16's medical record revealed an admission date of 11/29/17 with diagnoses that included dementia, chronic obstructive pulmonary disease and congestive heart failure. Further review of the medical record including physician's orders revealed Resident #16 was admitted to hospice on 04/25/19. Review of the hospice records including visitation notes and assessments revealed the last visitation note and assessment in the medical record was from 07/05/23. On 10/18/23 at 8:25 A.M. interview with medical records (MR) #571 revealed she had not received any documentation from Resident #16's hospice provider for several months. MR #571 indicated she assumed Resident #16 was no longer on hospice services and did not ask or inform anyone of not receiving any hospice documentation.…

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

Based on observation, review of an end of shift checklist, facility policy and procedure review and interview the facility failed to ensure food was stored and prepared under sanitary conditions to prevent contamination spoilage and/or food borne illness. This had the potential to affect 74 of 74 residents who received meal trays from the kitchen. The facility identified three residents (#58, #74 and #475) who received nothing by mouth. Findings include: On 01/19/22 beginning at 10:37 A.M. an initial tour of the kitchen with Dietary Supervisor #106 revealed the following concerns: A container of Barolta Pasta was opened, not sealed or dated when open. A container of Barolta elbow macaroni pasta was opened and not dated when opened. The walk-in freezer had beef burgers opened to air. The box was opened and the plastic bag the burgers were in was also opened and not sealed. A box of grilled chicken breast fillets was opened, the plastic bag was opened to the freezer air and not sealed. The reach in refrigerator had four rusty shelves. The reach in refrigerator had seals deteriorating…

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 and interview the facility failed to ensure all resident rooms were in good repair and properly cleaned. This affected four residents (#60, #35, #19 and #74) of 77 residents residing in the facility. Findings include: 1. On 01/18/22 at 1:23 P.M. observation of Resident #35 and #60's shared room revealed a large gouge in the wall approximately three inches by one foot. On 01/18/22 at 2:01 P.M. interview with Resident #60 revealed concerns her room was dirty. Observation during the interview revealed dust around the base board, a piece of paper and wrappers among other dirt on the floor near the resident's television. On 01/19/22 at 8:23 A.M. observation of Resident #60 and Resident #35's room revealed the floor had not been cleaned and the same dirt as previously observed on 01/18/22 was still present. Interview with Resident #60 at the time of the observation confirmed the room had not been swept since yesterday. On 01/19/22 at 2:04 P.M. the condition of the resident's room remained the same. There was dust, pieces of rubber and papers on the…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure insulin and tuberculin solution were labeled appropriately after opening. This affected eight residents (#4, #479, #1, #22, #52, #175, #65 and #39 and had the potential to affect all 77 residents residing in the facility. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/05/20 with diagnosis of diabetes mellitus type two. Review of Resident #4's physician's orders revealed an order for Novolog insulin solution and Basaglar insulin solution for daily use. On 01/19/22 at 8:32 A.M. observation with Registered Nurse (RN) #177 revealed Resident #4's Novolog insulin solution and Basaglar solution were opened and had been used but did not include a date as to when they had been opened. Interview on 01/19/22 at 8:32 A.M. with RN #177 confirmed the medications were open, used and undated. 2. Review of Resident #479's medical record revealed an admission date of 01/15/22 with diagnosis of diabetes mellitus type two. Review of 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 and interview the facility failed to ensure resident room repairs and issues were addressed timely after identification from staff. This affected 36 rooms of 52 rooms in the facility. The facility census was 77. Findings include: On 01/19/22 at 3:22 P.M. interview with Maintenance #184 revealed he did a walk through the facility and had identified areas of resident rooms including walls that needed repaired. Maintenance #184 revealed he had started on the North end of the facility but had only fixed one room as of this date. Review of the Room to Room Inspection Sheets, dated 11/17/21 revealed the following environmental issues were identified that needed repaired/addressed: room [ROOM NUMBER] needed painted behind bed. room [ROOM NUMBER] needed painting in the bathroom and the toilet was leaking. room [ROOM NUMBER] the door jams needed painted and minor touch up on the walls. room [ROOM NUMBER] the paint needed touched up behind bed B and the bathroom. The door jams need touched up. room…

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 resident funds review and interview the facility failed to ensure Resident #3's funds were safeguarded, properly managed and not returned to the Treasurer of Ohio following stimulus money received by the resident. This affected one resident (#3) of 43 residents identified to have personal funds managed by the facility. Findings include: On 01/20/22 at 5:20 P.M. review of the resident personal fund accounts with the Administrator, who was onsite at the facility and Business Office Manager (BOM) #149 via phone revealed the following: Resident #3 was reviewed for spend down notice. Record review revealed the resident's representative, her sister was sent a spend down letter on 11/12/21. The letter indicated Resident #3's personal funds exceeded the $2000.00 Medicaid allowance. The resident trust had a balance of $3957.52. The letter advised that if the account was over the $2000.00 limit, the resident would no longer qualify for Medicaid and indicated due to the fact this balance was over the $2000.00 limit, please take the necessary steps to spend down the money immediately…

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, facility policy and procedure review and interview the facility failed to ensure residents and/or resident representatives received bed hold notification prior to transfer to the hospital. This affected two residents (#74 and #76) of two residents reviewed for hospitalization. Findings include: 1. Review of Resident #76's medical record revealed an admission date of 09/30/21 with diagnoses including diabetes, congestive heart failure and hypertension. Further review of the medical record revealed the resident was hospitalized from [DATE] through 11/11/21. The resident returned to the facility on [DATE]. The medical record did not contain evidence the resident or resident representative were notified of the facility bed hold procedure. Further review of the medical record revealed the resident was hospitalized on [DATE] and did not return to the facility. The medical record did not contain evidence the resident or resident representative were notified of the facility bed hold policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #65 and Resident #69, who required staff assistance for activities of daily living received timely and adequate assistance with oral care and/or showers. This affected two residents (#65 and #69) of two residents reviewed for activities of daily living. Findings include: 1. Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including constipation, cognitive communication disorder, dysphagia, unexpected lack of expected normal physiological development in childhood, hypertension, oxygen dependent, anemia, diverticulosis, scoliosis, angina pectoris, bilateral cataracts, Alzheimer's disease, and Type 2 diabetes. Review of the 01/18/21 Activity of Daily Living (ADL) plan of care revealed the resident may require assistance with ADL's and may be at risk of developing complications associated with decreased ADL self-performance. Interventions included I can perform…

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, facility policy and procedure review and interview the facility failed to ensure urinary drainage bags were maintained without potential for contamination to decrease the risk of urinary tract infections and/or failed to ensure resident catheter orders were comprehensive and implemented as written. This affected two residents (#7 and #60) of two residents reviewed for urinary/indwelling catheters. The facility identified six residents with urinary catheters. Findings include: 1. Review of Resident #7's medical record revealed an admission date of 08/09/19 with diagnoses including hypertension, benign prostate hyperplasia (enlarged prostate gland), obstructive and reflux uropathy (a blockage in the urinary tract). Review of the alteration in elimination due to a urinary catheter related to obstructive uropathy and urinary retention plan of care initiated 08/14/19 revealed interventions including change urinary catheter as ordered and as needed. Review of the non-compliance…

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 nutritional formula information and interview the facility failed to provide the appropriate tube feeding to meet nutritional needs for one resident (Resident #475) and failed to timely address a significant weight loss for one resident (Resident #53). This affected two residents (#53 and #475) of four residents reviewed for nutrition. The facility identified four residents with feeding tubes and ten residents with unplanned significant weight changes. Findings include: 1. Review of Resident #53's open medical record revealed diagnoses including Alzheimer's disease, anemia, and type 2 diabetes mellitus. A weight of 195 was recorded 11/05/21 and a weight of 184 pounds was recorded on 12/07/21. A dietary assessment narrative, dated 12/15/21 at 6:00 P.M. indicated Resident #53 had a significant weight loss of 5.6% of his body weight in one month. However, Resident #53 had a significant weight gain of 10.8% in six months. The weight loss occurred post COVID-19 as the resident became more mobile. The note indicated Resident #53 was eating…

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 #19's oxygen was delivered at the rate ordered and failed to notify the physician when the resident's rate of oxygen was increased. This affected one resident (#19) of two residents reviewed for respiratory care. Findings include: Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type 2 diabetes, dysphagia, atherosclerotic heart disease of native coronary artery and Barrette's esophagus. Review of the care plan, dated 10/22/21 revealed Resident #19 required oxygen due to diagnoses of chronic obstructive pulmonary disease, pneumonia, tracheostomy, and respiratory failure . Interventions included administer oxygen as ordered, medication as ordered, monitor lung sounds as ordered, monitor oxygen saturation as ordered, respiratory assessment/monitoring (by nurse), observe for signs of dyspnea that was labored respirations, low oxygen…

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, facility guidance review and interview the facility failed to ensure laboratory testing for Resident #33 was obtained as ordered. This affected one resident (#33) of five residents reviewed for unnecessary medication use. Findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, major depressive disorder, dementia and Alzheimer's disease. Review of Resident #33's current physician's orders revealed an order for Seroquel 25 milligrams (antipsychotic) with directions to give half a tablet by mouth two times a day for dementia and an order (initiated 09/15/20) to obtain a fasting lipid panel annually in September due to the anti-psychotic medication use. Review of Resident #33's laboratory testing revealed Resident #33's last had a fasting lipid panel completed on 09/16/20. On 01/20/22 at 3:59 P.M. interview with Director of Nursing #103 confirmed Resident #33's fasting lipid panel was last done on…

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

Based on record review, review of Loeb Minimum Criteria for Initiating Antibiotic Therapy, review of the facility policy and procedure and interview the facility failed to ensure antibiotic use was appropriate to treat an infection for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #60's medical record revealed an admission date of 03/19/19 with diagnoses including acute kidney failure, diabetes and dementia. Review of the alteration in elimination due to diagnoses of diabetes, dementia, wound to buttocks and indwelling catheter plan of care initiated 03/26/19 revealed interventions included to monitor for signs and symptoms such as elevated temperature, dysuria (painful urination), flank pain, hematuria (blood in urine) and/or foul smelling urine, report to the physician and seek diagnosis and treatment promptly. Review of the resident was at risk for infection related to urinary tract infection plan of care initiated 04/08/21 revealed interventions included give antibiotic therapy 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.