Laurels Of Steubenville The

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 Resident #21, who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections (UTI) and failed to ensure Resident #21, who was incontinent of bowel, received appropriate treatment and services to restore as much normal bowel function as possible. This affected one resident (#21) of one resident reviewed for bowel and bladder incontinence and UTI. The facility census was 86. Findings include: Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic respiratory failure, type two diabetes mellitus, malnutrition, neuropathy, asthma, chronic obstructive pulmonary disorder (COPD), muscle weakness, antibiotic resistance, depression, and pacemaker. Review of the Minimum Data Set (MDS) assessment completed on 12/01/24 revealed a Brief Interview for Mental Status (BIMS) score of 13,…

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 oxygen was administered as ordered by the physician for Resident #289 and failed to ensure oxygen tubing was dated when changed for Residents #289 and #292. This affected two residents (#289 and #292) of three residents reviewed for oxygen administration. The facility identified 18 residents (#1, #3, #15, #16, #21, #34, #44, #62, #70, #71, #139, #235, #284, #285, #289, #292, #295 and #297) who utilized oxygen. The facility census was 86. Findings include: 1. Review of the medical record for Resident #289 revealed an admission date of 03/13/25. Diagnoses included sepsis, muscle weakness, congestive heart failure, atrial fibrillation, sleep apnea, arthritis, kidney failure and pulmonary fibrosis. Review of the care plan dated 03/13/25 revealed Resident #289 had difficulty breathing and was at risk for respiratory complications. Interventions included observing for difficulty breathing. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure pre and post dialysis assessments were consistently completed for Resident #66. This affected one resident (#66) of one resident reviewed for hemodialysis services. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admission date of 02/04/25. Diagnoses included urinary tract infection, kidney disease, muscle weakness and diabetes. Review of the care plan dated 02/04/25 revealed Resident #66 had a need for dialysis due to end stage kidney disease. Interventions included dialysis Tuesday, Thursday and Saturday, administering medications as ordered, observing for side effects and ineffectiveness of medications, checking and reinforcing the dressing at the access site as needed, and utilizing the dialysis communication form to communicate with the dialysis center. Upon return from the dialysis center the communication book would be reviewed and any updates provided to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure parameters were in place for the administration of pain medication and failed to ensure nonpharmacological interventions were attempted prior to administering narcotic pain medication to Resident #3. In addition, the facility failed to ensure insulin was given according to the physician's orders for Resident #21. This affected two residents (#3 and #21) of five resident reviewed for unnecessary medications. The facility census was 86. Findings include: 1. Review of the medical record for Resident #3 revealed and admission date of 06/11/24. Diagnoses included depression, bronchitis, history of stroke and failure to thrive. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired. She required setup help for eating, partial to moderate assistance for oral hygiene, substantial to maximum assistance for showering and dressing and was completely dependent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medial record and interview with staff, the facility failed to ensure a physician's order was written for laboratory tests obtained and laboratory tests were obtained immediately (STAT) as ordered by the physician for Resident #2. This affected one resident (#2) of five residents reviewed for antibiotic stewardship. The facility census was 86. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, cerebral infarction, diabetes, moderate protein-calorie malnutrition, epilepsy, abdominal aortic aneurysm, kidney failure, hemiplegia left side, myocardial infarction, obstructive and reflux uropathy, hypertensive heart disease, chronic pain syndrome, presences of cerebrospinal fluid device, and nontraumatic subarachnoid hemorrhage. Review of the Nurse's Note dated 02/05/25 at 11:31 A.M. revealed the Nurse Practitioner (NP) was called because Resident #2 was acting lethargic, with very little verbal…

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, interview with staff, review of information from the PneumoRecs Vax Advisor application and facility policy review, the facility failed to ensure the pneumonia vaccine was up to date for Resident #19. This affected one resident (#19) of five residents reviewed for vaccination status. The facility census was 86. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, epilepsy, chronic kidney disease, and shortness of breath. Review of the immunizations revealed Resident #19 had the pneumococcal polysaccharide vaccine 23 (PPSV23) pneumonia vaccine on 11/19/23. Review of the PneumoRecs Vax Advisor application revealed if a resident over [AGE] years of age had the PPSV23 and no other pneumonia vaccine they should be administered the Pneumonia conjugate vaccine 15 (PCV) or PCV20 after one year of administration of the PPSV23. On 03/20/25 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.

Based on review of schedules and interviews, the facility failed to ensure the Director of Nursing (DON) did not work as a charge nurse when the facility census was greater than 60. This had the potential to affect all 79 residents residing in the facility. Findings include: Review of nursing schedules from 10/15/22 to 11/17/22 revealed the DON worked as a charge nurse on 11/12/22 between 6:00 P.M. and 10:00 P.M. when the census was 80 and on 11/13/22 between 3:00 P.M. and 6:00 P.M. when the census was 79. On 11/15/22 at 4:22 P.M., the DON verified she worked as a charge nurse on the evening of 11/12/22 and the afternoon of 11/13/22. The DON stated she was unaware she was unable to work as a charge nurse if the census was greater than 60. On 11/17/22 at 12:15 P.M., the DON verified when she worked as a charge nurse on 11/12/22 the census was 80. On 11/17/22 at 12:41 P.M., the Administrator verified when the DON worked as a charge nurse on 11/13/22 the census was 79. The Administrator stated she was not aware the DON could not fulfill charge nurse requirements if census was greater…

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 revealed the facility failed to ensure staff waited for permission to enter a resident's room while she was sleeping. This affected one resident (Resident #177) of three reviewed for dignity. The facility census was 79. Finding include: Review of the medical record revealed Resident #177 was admitted to the facility on [DATE]. Diagnoses included diabetes, anxiety, depression, chronic kidney disease, atrial fibrillation, back and hip pain, bradycardia, supranuclear palsy, and gastroesophageal reflux. Observation on 11/14/22 at 3:06 P.M. revealed Resident #177 was in bed sleeping. Maintenance #203, with an employee for the telephone company, knocked on the door of Resident #177's room and went into her room without waiting for the resident to wake up and give her permission to enter. Resident #177 woke up when the telephone company employee moved her bedside table and Maintenance #203 explained to her what they were doing in her 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.

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 the call light was within reach for Resident #177. This affected one resident (Resident #177) of 24 residents observed for call lights within reach. The facility census was 79. Findings include: Review of the medical record revealed Resident #177 was admitted to the facility on [DATE]. Diagnoses included diabetes, anxiety, depression, chronic kidney disease, atrial fibrillation, back and hip pain, bradycardia, supranuclear palsy, and gastroesophageal reflux. Observation on 11/14/22 at 11:46 A.M. revealed the call light for Resident #177 was on the chair on the other side of the bed. Resident #177 stated she could not reach her call light because she was not able to walk over to the chair to get it. Interview on 11/14/22 at 11:47 A.M., Licensed Practical Nurse (LPN) #238 verified the call light for Resident #177 was not within her reach. Observation on 11/15/22 at 8:17 A.M. revealed Resident #177 was up…

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 privacy was maintained during a medical treatment for Resident #176. This affected one resident (Resident #176) of one reviewed for privacy. The facility census was 79. Findings include: Review of the medical record revealed Resident #176 was admitted to the facility on [DATE]. Diagnoses included acute pulmonary edema, restless leg syndrome, hypertensive heart disease, low back pain, osteoarthritis, and intervertebral disc disease. Observation of wound care on 11/17/22 at 1:00 P.M. with Licensed Practical Nurse (LPN) #301 for Resident #176 revealed she provided wound care to both the residents heels without closing her door to the hallway or pulling the privacy curtain to maintain privacy. Interview on 11/17/22 at 1:15 P.M. LPN #301 verified she had not provided privacy to Resident #176 during wound care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive bowel and bladder assessment was completed for Resident #67. This affected one (Resident #67) of nine residents reviewed for assessments. The facility census was 79. Finding include: Review of the medical record for Resident #67 revealed an admission date of 12/21/21. Diagnoses included generalized muscle weakness, aphasia, and gastro esophageal reflux disease (GERD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 had impaired cognition. He was incontinent of bowel and bladder and required extensive assistance of two staff for toilet use. Review of the care plan dated 10/28/22 revealed Resident #67 was incontinent of bowel and bladder due to a developmental delay. Interventions included checking and changing the resident's brief every two hours and changing clothing after incontinence care as needed. Review of the medical record from 12/21/21 through 11/16/22 revealed 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 record review, review of the Centers for Medicare and Medicaid Services' (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and staff interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed as required. This affected one (Resident #5) of three residents closed records reviewed. The census was 79. Findings include: Review of the closed medical record for Resident #5 revealed an admission date of [DATE] with diagnoses including heart failure, Parkinson's disease, type two diabetes mellitus, hypertension, and cardiomyopathy. Resident #5 expired on [DATE]. Review of the completed Minimum Data Set (MDS) 3.0 Assessments for Resident #5 revealed an Entry Assessment was completed on [DATE] and an admission Assessment was completed on [DATE]. No other MDS 3.0 Assessments were available in the electronic health record. Review of the progress note dated [DATE] at 7:05 A.M. revealed Resident #5 expired in the facility and her time of death 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 observations, review of the medical record, review of activity calendars, review of activity attendance sheets, and staff interviews revealed the facility failed to provide activities to Resident #68. This affected one (Resident #68) of two residents reviewed for activities. The facility census was 79. Findings include: Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included dementia, Down's syndrome, epilepsy, affective mood disorder, bipolar disorder, psychosis, obstructive sleep apnea, peripheral vascular disease, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had severely impaired cognition. Review of the admission activity assessment dated [DATE] revealed gospel and country music were very important. His favorite activities were preaching and music, but he also enjoyed sports, video games, singing, played the guitar at one time, loves taking rides in the car,…

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 interview the facility failed to ensure daily weights for Resident #176 were obtained as ordered. This affected one (Resident #176) of 24 resident records reviewed. The facility census was 79. Findings include: Review of the medical record revealed Resident #176 was admitted to the facility on [DATE]. Diagnoses included acute pulmonary edema, restless leg syndrome, hypertensive heart disease, low back pain, osteoarthritis, and intervertebral disc disease. Review of the medical record revealed at the time of the survey there was not Minimum Data Set (MDS) 3.0 assessment available. Review of the November 2022 physician's orders revealed Resident #176 had an order dated 11/07/22 to obtain a daily weight for congestive heart failure. Review of the daily weights in Point Click Care (PCC) revealed no documentation on weights for Resident #176 on 11/08/22, 11/09/22, 11/10/22, 11/11/22, 11/12/22, 11/13/22, and 11/14/22. Review of the November 2022 medication administration…

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 a medical record, observations, and staff interviews the facility failed to ensure a deep tissue injury (DTI) was assessed and an order was obtained timely for Resident #176. This affected one (Resident #176) of two residents reviewed for pressure ulcers. The facility census was 79. Findings include: Review of the medical record revealed Resident #176 was admitted to the facility on [DATE]. Diagnoses included acute pulmonary edema, restless leg syndrome, hypertensive heart disease, low back pain, osteoarthritis, and intervertebral disc disease. Review of the medical record revealed at the time of the survey there was not Minimum Data Set (MDS) 3.0 assessment available. There was no skin assessment for Resident #176 from her day of admission on [DATE]. Review of the medical record revealed there were no progress notes from admission on [DATE] or 11/06/22. The first progress notes and assessment were dated 11/07/22. Review of the Nursing Comprehensive assessment dated [DATE] revealed 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 observation, medical record review, and interview the facility failed to implement appropriate care plan interventions and/or orders for fall prevention for two (Residents #29 and #63) of five residents reviewed for accidents. The facility census was 79. Findings include: 1. Review of Resident #29's medical record revealed diagnoses including dementia, chronic obstructive pulmonary disease, type two diabetes mellitus, chronic kidney disease, hypertension, and Parkinson's disease. A care plan initiated 01/05/22 indicated Resident #29 was at risk for falls related injuries and weakness, Parkinson's disease, dementia, and poor safety awareness. The care plan indicated Resident #29 chose not to seek staff assistance with transferring at times and chose to self-ambulate and self-transfer. Interventions included keeping the environment as safe as possible with even floors. Another intervention which was added was use of a mat to the floor. Review of the nursing notes and/or Situational Background Assessment…

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 clinical assessment was completed before and after each dialysis session for Resident #51. This affected one (Resident #51) of one resident reviewed for dialysis. The census was 79. Findings include: Review of the medical record for Resident #51 revealed an admission date of 07/09/22 with diagnoses including type two diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Review of the physician's orders for November 2022 identified orders for hemodialysis every Tuesday, Thursday, and Saturday. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had no cognitive impairment. The assessment indicated Resident #51 received dialysis treatments. Review of the Hemodialysis Communication Forms dated 08/16/22 through 11/15/22 revealed Resident #51 was not clinically assessed before going to dialysis or upon returning from dialysis treatment on 08/23/22, 08/27/22, 08/30/22, 09/06/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication, for Residents #34 and #58. This affected two (Residents #34 and #58) of six residents reviewed for unnecessary medication use. The facility census was 79. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 12/13/16. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, ataxic gait (impaired ability to walk), and partial weakness of the dominant right side. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. He received scheduled and as needed pain medication. Review of the physician's orders for November 2022 revealed an order for Nucynta, a medication used to treat pain, 50 milligrams (mg) four times per day (QID) as needed. Review of the Medication Administration Record (MAR) for October 2022…

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 #42's recommendation for a gradual dose reduction (GDR) was addressed by the physician. This affected one (Resident #42) of six residents reviewed for unnecessary medications. The facility census was 79. Findings include: Review of the medical record for Resident #42 revealed an admission date of 01/26/22. Diagnoses included dementia, visual hallucinations, and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the physician's orders for November 2022 revealed an order for Risperdal, an antipsychotic medication, 0.5 milligrams (mg) two times per day. Review of the consultation report 01/28/22 by Pharmacist #302 revealed a recommendation to reduce the dosage of Risperdal with a plan to discontinue the medication. There was no evidence the physician reviewed the recommendation or addressed it. Interview on 11/16/22 at 1:05 P.M. 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 observation, record review and interview the facility failed to ensure evening snacks were provided to all residents. This affected ten residents (#20, #41, #48, #75, #192, #51, #46, #8, #33 and #35) and had the potential to affect all 95 residents residing in the facility. Findings include: Review of Resident Council Minutes dated 02/11/19 to 02/10/20 revealed during the meetings held on 02/11/19, 03/11/19, 04/08/19, 06/03/19, 07/15/19, 10/14/19 and 02/10/20 the residents present at the meeting voiced concerns regarding snacks not being delivered every night or they were delivered after 9:00 P.M. when the residents were asleep or not delivered if their door was shut. The council minute notes revealed staff were provided education each month that concerns were noted. Review of the snack list revealed Resident #192 was to receive a turkey sandwich with cheese, Resident #51 a deli sandwich, Resident #46 cottage cheese with tomatoes, Resident #8 ham and cheese on gluten free bread, Resident #33 a meat sandwich and Resident #35 deli sandwich. Observation on 02/27/20 at 8:42…

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 Preadmission Screening and Resident Reviews (PASARRs) were completed and accurate to capture changes in diagnosis warranting a reassessment. This affected four residents (#9, #24, #34 and #51) of four residents reviewed for PASARR. Findings include: 1. Review of Resident #24's 08/09/17 PASSAR revealed no diagnoses under the question Does the individual have a diagnosis of any of the mental disorders listed below? The question was answered no. The list included other psychotic disorders and Schizophrenia. Record review revealed Resident #24's was admitted to the facility on [DATE]. Review of Resident #24's diagnoses list revealed an added diagnosis of unspecified psychosis not due to substance or known physiological condition added 11/12/17 and schizoaffective disorder added 10/19/18. Record review revealed as 02/25/20 the facility had not completed/submitted a new PASARR for the resident to capture the new diagnoses and to determine if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview the facility failed to maintain Resident #59's dignity related to the use of an indwelling urinary catheter. This affected one resident (#59) of two residents observed with an indwelling urinary catheter. Findings include: Medical record review revealed Resident #59 was admitted to the facility on [DATE] with a diagnosis including urinary retention related to obstruction uropathy. Review of the quarterly Nursing Comprehensive assessment dated [DATE] and the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had an indwelling urinary catheter. On 02/24/20 at 12:16 P.M., observation during the lunch meal revealed Resident #59's indwelling catheter bag was attached to the underside of his specialized wheelchair uncovered. Yellow urine was observed in the catheter bag. On 02/24/20 at 2:35 P.M., observation revealed Resident #59 was sitting in his reclined specialized wheelchair in the common area across from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide a dining table at an appropriate height to accommodate Resident #57's needs. This affected one resident (#57) of one resident reviewed for accommodation of needs. Findings include: Medical record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, weakness, lack of coordination and pain in left shoulder. Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment, dated 12/17/19 revealed the resident required extensive assistance from one person for bed mobility, transfers, and dressing. For eating, the resident required supervision and set-up help. During observation on 02/24/20 at 12:10 P.M., Resident #57 was sitting in her wheelchair at a dining table in the main ding room. The top of table was level with the resident's upper chest, requiring the resident to reach up with her arms to access the food. During a subsequent observation on 02/27/20 at 5:10 P.M., 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 and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately completed for Resident #53 and Resident #86. This affected two residents (#53 and #86) of 31 residents whose MDS assessments were reviewed. Findings include: 1. Review of Resident #53's medical record revealed an admission dated of 04/02/18 with diagnoses including chronic kidney disease, cerebral infarction, contracted left elbow and peripheral vascular disease. Review of a 01/16/20 Skin and Wound Evaluation revealed a new in house acquired right buttock abrasion measuring 2.0 centimeters (cm) by 5.2 cm with a pink/red wound bed and light serous exudates. Review of a 01/16/20 Skin and Wound Evaluation revealed an in house acquired left buttock abrasion measuring 2.8 centimeters (cm) by 2.6 cm with a pink/red wound bed and light serous exudates. A 01/22/20 nurse's note indicated the physician visualized the areas on the buttocks and reviewed the Skin and Wound evaluations. The physician was aware of and agrees with the origin of wound being an abrasion that is…

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 develop, implement and provide residents/representatives with a baseline plan of care as required. This affected two resident (#58 and #284) of eight residents reviewed for baseline plans of care. Findings include: 1. Review of Resident #284's medical record revealed an admission date of 02/15/20 with diagnoses including major depressive disorder, unspecified psychosis, anxiety disorder and congestive heart failure. Review of the physician's orders included an order for the medication, Seroquel (an antipsychotic), an order for the medication, Sertraline (an antidepressant) and daily weights. Record review revealed no evidence the facility had provided the resident and the resident's representative with a summary of a baseline care plan that included but was not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed to ensure Resident #7, who was dependent on staff for personal care was provided timely care and care according to the resident's preferences. This affected one resident (#7) of five residents reviewed for activities of daily living (ADL). The facility identified 28 residents dependent on staff for bathing. The facility census was 95. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including a spinal cord injury, osteoarthritis and heart failure. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making, required extensive assist of two staff with personal hygiene and was dependent on staff for bathing. Review of the care plan titled ADL Self-Care Performance Deficit, revised 01/09/20 revealed Resident #7 had a very specific routine of how he preferred his daily ADL's to be completed.…

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 #27's hearing aids were in proper working order and failed to obtain hearing aids for Resident #34. This affected two residents (#27 and #34) of three residents reviewed for hearing. Findings include: 1. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, pulmonary fibrosis, and a history of falling. Review of the plan of care, dated October 2019 revealed no documentation of hearing aids. Review of the progress notes, dated October 2019 through 02/25/20 revealed no documentation of improperly working hearing aids. Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment, dated 12/17/19 revealed the resident required extensive assistance from one person for bed mobility, transfers and dressing. During an interview on 02/25/20 at 2:11 P.M., Resident #27 revealed she was very hard of hearing and had not been able to wear her hearing aids for a couple of weeks…

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 #14, who was at risk for falls was provided fall safety interventions as care planned. This affected one resident (#14) of two residents reviewed for accidents. Findings include: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, epilepsy and history of cardiovascular accident with right-sided weakness. Review of the plan of care, dated 06/18/19 revealed the resident as at risk for falls with an intervention to wear non-skid footwear when out of bed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/05/19 revealed Resident #14 required extensive assistance from one person for locomotion and extensive assistance from two persons for bed mobility and transfers. Review of a nursing progress note, dated 11/10/19 at 6:30 P.M., revealed Resident #14 was found on floor following a fall, without injury. On 02/25/20 at 11:23…

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 observation, record review and interview the facility failed to ensure adequate and necessary care and treatment was provided for Resident #42 related to the use of an indwelling urinary catheter. The facility also failed to ensure a bowel program was initiated for Resident #58 after a noted decline in bowel function. This affected one resident (#42) of three residents reviewed for UTI/catheters and one resident (#58) of one resident reviewed for bowel function. Findings include: 1. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including retention of urine, urinary tract infection, indwelling foley catheter and fracture of right femur. Review of Resident #42's nursing progress notes and orders dated 02/2020 revealed on 02/13/20 Resident #42 had complaints of bladder spasms and requested a prescription for Pyridium for the spasms. The physician was notified, and new orders were received for Pyridium 100 milligrams (mg) three timed daily for three days and for 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 observation, record review and interview the facility failed to ensure physician orders were in place for the administration of oxygen, failed to ensure humidification was properly used and/or failed to ensure respiratory equipment was maintained in a clean/sanitary manner for Resident #25, #37, and #56. This affected three residents (#25, #37 and #56) of four residents reviewed for respiratory care. Findings include: 1. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including shortness of breath and heart failure. Review of the plan of care, dated 07/01/19 revealed Resident #56 would be free of signs and symptoms of respiratory infections. Observation on 02/24/20 at 9:50 A.M. and again at 11:00 A.M., revealed Resident #56's oxygen tubing/nasal cannula was draped over the edge and laying in the trash can. The resident was not in the room at the time of the observation. Record review revealed the resident did not have a physician order for the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure Resident #51 received behavior health services to assist the resident to attain or maintain her highest level of well-being. This affected one resident (#51) of four residents reviewed for Preadmission Screening and Resident Review (PASARR) Identification Screen. Findings include: Review of the Preadmission Screening and Resident Review (PASARR) Identification Screen dated 11/12/19 revealed no evidence Resident #51 had major depressive disorder or anxiety disorder, the resident consented to receiving mental health and counseling services. Further review revealed the resident did not meet nursing home criteria and her needs could be met in an appropriate community setting that could provide for her ongoing need for psychiatric support. A group home, assisted living facility should be explored for the resident. The resident had been evicted from her apartment recently and that was why she was being placed in a nursing home until other…

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 the justified use of narcotic pain medication for Resident #284 and Resident #58. The facility failed to ensure parameters were in place related to medication administration, failed to ensure medication was administered only after a comprehensive pain assessment had been completed and/or failed to ensure evidence of non-pharmacological interventions prior to the medication administration. This affected two residents (#58 and #284) of five residents reviewed for unnecessary medication use. The facility identified five residents on a pain management program. Findings include: 1. Review of Resident #284's medical record revealed an admission date of 02/15/20 with diagnoses including osteoarthritis and an artificial hip joint. A 02/15/20 plan of care was developed for actual pain acute/chronic related to chronic pain and history of back pain. The plan of care revealed the use of non pharmacological interventions. Review of the 02/20/20 admission Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent…

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 #190's medical record was complete and accurate related to infection and antibiotic use. This affected one resident (#190) of 31 residents whose medical records were reviewed. Findings include: Record review revealed Resident #190 was admitted to the facility on [DATE] and re-admitted on [DATE] after a hospitalization. The resident's diagnosis list indicated respiratory syncytial virus (RSV) detected on 02/20/20. Review of Resident #190's hospital discharge orders, dated 02/20/20 revealed an order for the antibiotic, Amoxicillin-pot clavulanate 875 milligrams (mg) every 12 hours for seven days (quantity #14). Review of Resident #190's medication administration records (MAR) dated 02/2020 revealed on 02/21/20 an order was entered for Amoxicillin 875 mg one tablet by mouth every 12 hours for bacterial infection for 7 days. The order was discontinued and rewritten on 02/21/20 for Amoxicillin 875-125 mg one tablet every 12 hours for RSV 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 and interview the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent the unnecessary/inappropriate use of antibiotics. This affected two residents (#58 and #195) of five residents reviewed for infections. Findings include: 1. Record review revealed Resident #195 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, cellulitis, acute and chronic respiratory failure, pneumonia, acute upper respiratory infections, atelectasis, acute bronchitis, heart failure, cough, dyspnea and history of lung cancer. Review of Resident #195's chest x-ray results dated 02/11/20 and 02/17/20 revealed the resident had cardiomegaly. There was no evidence of pneumonia or acute cardiopulmonary disease process noted. Review of Resident #195's nursing progress notes dated 02/18/20 revealed the resident had noted weight gain, increase sputum of yellow/green color and wheezing. New orders were received to start Aldactone…

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.