Arbors At Stow

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to adequately manage Resident #6's pain following a fall. This affected one resident (#6) of three reviewed for pain management. The facility census was 131. Findings include:Record review revealed Resident #6 admitted on [DATE] with diagnoses including anxiety, personality disorder, depression, violent behavior, paranoid schizophrenia, polyneuropathy (nerve pain).Review of care plan dated 11/17/25 revealed Resident #6 was at risk for falls related to generalized weakness, history of falls and impaired cognition with decreased safety awareness with intervention to encourage the resident to use the call light. Resident #6 was at risk for pain related to polyneuropathy with intervention to administer medications per orders and monitoring for effectiveness.Review of physician's orders dated 11/17/25 revealed orders for Tramadol 50 milligrams (mg) every 12 hours as needed for pain, Acetaminophen 325 mg every six hours as needed for pain and Lyrica 50 mg three…

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 record review and staff interview, the facility failed to ensure individualized behavioral health interventions were implemented to meet Resident #77's mental health needs tp prevent suicidal ideation with suicidal attempt. This deficient practice affected one (Resident #77) of two residents reviewed for mood and behavior. The facility census was 131.Findings include: Resident #77 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, personality disorder, and major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 was cognitively intact and required hands-on assistance of one staff person for activities of daily living.Review of Resident #77's admission documentation revealed he was admitted from a psychiatric hospital, where he had been transferred from an assisted living facility following…

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, review of the Self-Reported Incident and interview with the staff the facility failed to ensure an incident of potential abuse was documented in the medical record of Resident #31. This affected one resident (Resident #31) of 21 residents reviewed for abuse.Findings include:Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including vascular dementia anxiety disorder, psychosis, cerebral infarction, hemiplegia of the left side, contractures of the right hip, left hip, right knee, left knee, peripheral vascular disease, mood disorder, tremors, pain, insomnia, epilepsy and hypertension.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #31 had severely impaired cognition. Review of the facility's Self-Reported Incident dated 09/17/25 revealed Resident #31 had reported to the nurse and aide on duty that during care on the previous night, an aide allegedly held a towel up to her face. 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, interview and record review the facility failed to follow proper infection control techniques for residents on Enhanced Barrier Precautions (EBP). This affected one resident (#75) of three observed for EBP. The facility failed to maintain hand hygiene during medication administration and disinfect a glucometer meter after use. This affected one resident (#9) of four observed for infection control techniques during medication administration. The facility census was 131.1.Review of Resident #75's medical records revealed an admission date 11/24/25. Diagnoses included surgical amputation of the right toes, muscle weakness and dementia. Review of care plan dated 12/29/25 revealed Resident #75 required EBP related to diabetic foot ulcer. Interventions included use gown and gloves when providing direct resident care and utilize EBP when providing high contact resident care that included wound care. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of completed cleaning schedules, and review of facility policies, the facility failed to ensure the kitchen was clean and sanitary and food items were properly stored, which had the potential to affect all residents who received food from the kitchen. The facility identified no residents as receiving nothing by mouth. The facility census was 125. Findings include: Observation of the kitchen on 01/06/25 from 8:40 A.M. to 9:20 A.M. with Dietary Manager (DM) #900 revealed the following concerns: -The wall mounted fan, which was off but pointed toward the tray line, had a visible buildup of black dirt and dust on the blades and on the front and back of the metal guards. -The vents in the commercial hood had an accumulation of black dirt and debris. -The six gas burner cooktop had dried food and debris around the burners. -The left side of the double convection oven, which was next to the six burner cooktop, had dried food splatters on the outside of the unit. -The base of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the facility policy, and interview with staff the facility failed to ensure the water temperature on the 200 unit was maintained at a comfortable temperature. This affected seven residents (Resident #17, #29, #40, #51, #74, #83, and #110) who resided on the 200 hall and had the potential to affect all 23 residents on the 200 unit ( #17, #29, #30, #34, #35, #40, #45, #47, #50, #51, #54, #58, #65, #74, #79, #83, #93, #86 #97, #98, #103, #110, #117). The facility census was 125. Findings include: On 01/07/25 at 9:30 A.M. an interview with Certified Nursing Assistant #520 revealed the 200 unit never had enough hot water for showers and the water never really got hot. Observation on 01/07/25 at 10:00 A.M. revealed the hot water temperature in the central bathing room on the 200 unit was 105 degrees Fahrenheit (F), the hot water in Resident #17 and 51's room was 98 degrees F, and the hot water in Resident 40 and 83's Room was 88 degrees F. Observation of water temperatures with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain acceptable infection control practices to prevent the spread of infection during wound care for Resident #37 and failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #2's, Resident #9's, Resident #87's and Resident #120's medication administration. This affected one resident (#37) out of three residents (Resident #37,#27,#49) reviewed for wound care and four out of ten residents observed for medication administration. The facility census was 125 residents. Findings include: 1. Clinical record review revealed Resident #2 was admitted on [DATE] with diagnoses including respiratory, cerebral and heart disease, bipolar disorder with psychotic features, depression, diabetes mellitus and gastroesophageal reflux disease. A review of Resident #2's physician orders indicated to administer the following medications orally between 7:00 A.M. and 11:00 A.M.: - Tagamet 200 milligrams (mg) 200 mg…

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, review of the medical record, review of the facility policy and interview with staff the facility failed to ensure hair care was provided to Resident #35 and Resident #40. This affected two residents ( Resident #35 and #40) out of five reviewed for activities of daily living (ADL). The facility census was 125. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, aphasia, cerebral infarction, atrial fibrillation, intracerebral hemorrhage, psychosis, peripheral vascular disease, congestion heart failure, osteoarthritis, allergic rhinitis, insomnia, hyperlipidemia, major depressive disorder, generalized anxiety disorder, over active bladder, and vitamin D deficiency. Review of the plan of care dated 08/29/23 revealed Resident #35 had an ADL self care performance deficit related to anxiety, cognitive impairment, congestive heart failure, cerebral vascular accident, pain, dementia, depression, 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview the facility failed to provide adequate supervision to Resident #7 to prevent Resident #7 from obtaining an over-the-counter medication and possible ingestion of the medication. This affected one out of three residents reviewed for accidents. Findings include: Clinical record review revealed Resident #7 was re-admitted on [DATE] with diagnoses including dementia, malnutrition, stage three kidney failure, high blood pressure, atherosclerotic heart disease, anxiety, disorientation, heart disease with heart failure, irritable bowel syndrome, auditory hallucinations, hypothyroidism, chronic inflammation of the gallbladder, depression, insomnia, viral hepatitis, bipolar disorder with psychotic features, old heart attack, gastroesophageal reflux disease, obsessive compulsive disorder, borderline personality disorder, dependent personality disorder,…

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, review of pharmacy recommendation, and interview the facility failed to address pharmacy recommendation timely for Residents #7, #35, and #90. This affected three residents (#7, #35, and #90) of five reviewed for unnecessary medications. The facility census was 125. Findings include: 1. Review of medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic kidney disease, anxiety disorder, disorientation, altered mental status, hypertensive heart disease, irritable bowel syndrome, auditory hallucinations, hypothyroidism, cholecystitis, major depressive disorder, insomnia, bipolar disorder, obsessive compulsive disorder, borderline personality disorder, post-traumatic stress disorder, and schizophrenia. Review of the physician's orders revealed Resident #7 had an order for aripiprazole 20 milligrams every morning for bipolar disorder dated 11/16/24. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE]…

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, staff interview, and record review, the facility failed to ensure expired medications and supplies were discarded appropriately. This affected one resident (Resident #3) of eight residents reviewed for medication administration. The census was 125. Findings include: Clinical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, vascular dementia, multiple sclerosis, severe protein calorie malnutrition, hypothyroidism, major depressive disorder, spinal stenosis, mononeuropathy, fibromyalgia, anemia, vitamin D deficiency, obesity, and anxiety disorder. Review of Resident #3's physician order dated 10/23/24 revealed staff were to administer cholecalciferol (vitamin D3) oral capsule 125 milligrams (mg) 5000 unit (UT) orally in the morning related to vitamin D deficiency. Observation on the medication cart on nursing unit D on 01/07/25 at 7:55 A.M. revealed a container of cholecalciferol oral capsule 125 mg 5000 UT tablets with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview the facility failed to ensure Resident #34 received speech therapy as ordered. This affected one resident ( Resident #34) of one reviewed for therapy services. Finding include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, protein calorie malnutrition, iron deficiency anemia, atherosclerotic heart disease, major depressive disorder, benign prostatic hyperplasia, hypokalemia, anemia, hyperlipidemia, anxiety disorder, spinal stenosis, vitamin D deficiency, insomnia, dysphagia, and heart failure. Review of the physician's orders revealed Resident #34 had an order for Speech Therapy to evaluate and treat for dysphagia three to five days a week for 30 days dated 11/20/24. Review of the quarterly Minimum Date Set assessment dated [DATE] revealed Resident #34 had no swallowing concern, and was independent with eating. Observation of meal…

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 policy review, the facility failed to ensure documentation was complete and accurate for two residents (Residents #106 and #123) of 28 residents reviewed for accuracy of documentation. The facility census was 125. Findings include: 1. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), major depressive disorder, high blood pressure, peripheral vascular disease, congestive heart failure, schizophrenia, and multiple areas of arthritis. Review of the admission comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #106 was cognitively intact but had delusions. Resident #106 was able to perform all personal care independently. Review of the nursing progress dated [DATE] timed 5:35 A.M. authored by Licensed Practical Nurse (LPN) #496 revealed LPN #496 found Resident #106 sitting on the floor on her buttocks with her legs extended in front…

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 review of the medical record, review of the facility's investigation, interviews with facility staff, and review of the facility policy on elopement, the facility failed to ensure staff provided adequate supervision to prevent Resident #33 from leaving the facility unsupervised. This affected one resident (#33) of three residents reviewed for elopement/exit seeking behaviors. Findings included: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, cerebral infarction, atherosclerotic heart disease, peripheral vascular disease, alcohol abuse, insomnia, hypertension, osteoarthritis, vascular dementia, psychosis, major depressive disorder, and generalized anxiety disorder. Review of the physician's order, dated 03/06/24, revealed Resident #33 had an order to reside on the secure unit for safety, secondary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility self-reported incident (SRI), facility policy review, and interview the facility failed to ensure a resident was free from an incident of resident to resident abuse. This affected one resident (#113) of three residents reviewed for abuse. The facility census was 131. Findings include: Record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses included Wernicke's encephalopathy, receptive language disorder, anxiety disorder, anemia, insomnia, dementia, neuropathy, peripheral vascular disease, psychosis, schizoaffective disorder. Review of Minimum Data Set (MDS) 3.0 quarterly assessment revealed Resident #113 had severe cognitive impairment, delusional behaviors were displayed and rejection of care. Resident #113 needed assistance to eat but was independent for oral hygiene. Resident #113 was independent to roll left and right in bed, sit on the side of the bed and lie back in bed. Resident #113 was independent to walk ten feet. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview the facility failed to provide timely discharge notice as required related to a resident's transfer and discharge. This affected one resident (#133) of three residents reviewed for transfer/discharge. The facility census was 131. Findings include: Record review revealed Resident #133 was initially admitted to the facility on [DATE]. Medical diagnoses included traumatic brain injury, epilepsy, altered mental status, impulse control disorder, depression, insomnia, cocaine abuse, mood disorder, restlessness and agitation. Review of a nurse's note dated 10/11/24 at 5:46 P.M. revealed at 4:00 P.M. Resident #133 was at the nurse's station. Resident #133 was yelling and calling staff names when a co-resident tried to calm Resident #133 down. Resident #133 then hit the co-resident in the face. Call was placed to 911. Resident #133 was sent to the hospital for evaluation. Review of physician's orders dated 10/11/24 revealed a verbal order was given to send 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 provide a resident and the resident's guardian of the resident's bed hold. This affected one resident (#133) of three residents reviewed for transfer/discharge. The facility census was 131. Findings include: Record review revealed Resident #133 was initially admitted to the facility on [DATE]. Medical diagnoses included traumatic brain injury, epilepsy, altered mental status, impulse control disorder, depression, insomnia, cocaine abuse, mood disorder, restlessness and agitation. Review of a nurse's note dated 10/11/24 at 5:46 P.M. revealed at 4:00 P.M. Resident #133 was at the nurse's station. Resident #133 was yelling and calling staff names when a co-resident tried to calm Resident #133 down. Resident #133 then hit the co-resident in the face. Call was placed to 911. Resident #133 was sent to the hospital for evaluation. Review of physician's orders dated 10/11/24 revealed a verbal order was given to send Resident #133 to the emergency room 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a self-reported incident (SRI), facility investigation, review of an employee personnel file, review of a police report, facility policy review and interview, the facility failed to timely report an allegation of staff to resident abuse. This affected one resident (#92) of three residents reviewed for abuse. The facility census was 127 residents. Findings include: Review of Resident #92's medical record revealed an admission date of 09/07/23 and diagnoses including unspecified severe protein-calorie malnutrition, dementia without behavioral disturbance, major depressive disorder, history of COVID-19, dysphagia, cognitive communication deficit, and insomnia. Resident #92 had a guardian. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 was cognitively impaired and had inattention and disorganized thinking.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the resident's environment was kept clean, neat, well lit, and homelike. This affected Resident #83 and had the potential to affect all the 59 residents (#1, #3, #6, #10, #12, #15, #16, #18, #19, #24, #25, #26, #27, #29, #31, #35, #37, #39, #41, #42, #43, #44, #45, #47, #49, #51, #53, #55, #57, #61, #63, #67, #71, #72, #74, #77, #81, #82, #83, #85, #87, #89, #91, #93, #94, #95, #98, #100, #101, #102, #106, #107, #112, #114, #116, #273, #274, #322 and #323) on the 300, 500, and 600 pods. The census was 124. Findings include: 1. During observation on the 600-pod on 08/15/23 at 3:00 P.M. revealed all four ceiling fans had excessive amounts of dust and debris buildup on the blades and hanging over the edge. Observation on 08/15/23 at 3:24 P.M. of the 500-pod revealed four fans with excessive amounts of dust and debris buildup on the blades and hanging over the edge. Observation of the air intake vent on the 500 and 600 pods also had an excessive…

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 #110's urinary catheter bag had been covered. This affected one resident (#110) of one resident observed for urinary catheters. In addition, the facility failed to ensure staff knocked on a common bathroom door prior to entering. This affected Resident #88. The facility census was 124. Findings include: 1. Review of Resident #110's medical records revealed an admission date of 05/01/23. Diagnoses included dementia, altered mental status, need for personal care assistance, and muscle weakness. Review of the care plan dated 05/01/23 revealed Resident #110 had a urinary catheter for elimination. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had impaired cognition. The resident had a urinary catheter and was incontinent of bowel. Observation on 08/14/23 at 10:05 A.M.…

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 wishes regarding end-of-life measures were clearly identified in the medical record. This affected three residents (#19, #37 and #116) of three residents reviewed for Advanced Directives. The facility census was 124. Findings include: 1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, severe dementia with psychotic disturbance and delusional disorders. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and required extensive assistive of one staff using physical assistance for activities of daily living (ADL). Review of the physician's orders for Resident #19 revealed an order dated 06/05/23 and 07/05/23 for a Do Not Resuscitate Comfort Care Arrest (DNR CCA) meaning only comfort measures would be initiated in the event of an arrest. Review of the progress notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to report an incident of elopement to the state agency as required. This affected one resident (#272) of one resident reviewed for elopement and Self-Reported Incidents (SRI). The facility census was 124. Findings include: Review of Resident #272's medical record revealed an admission date of 09/08/22 with diagnoses including dementia and need for personal care assistance. Review of the care plan dated 05/30/23 revealed Resident #272 was at risk for elopement related to dementia and impaired safety awareness. Interventions included observe for wandering, cue, reorient, and supervise as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #272 had impaired cognition. The resident had wandering behaviors and supervision with ambulation. Review of progress note dated 06/17/23 revealed Resident #272 exited a secured unit after a nurse had opened the door to the unit. Resident #272 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 observation, interview, and record review the facility failed to prevent an elopement of Resident #272. This affected one resident (#272) of one resident reviewed for elopement. The facility census was 124. Findings include: Review of Resident #272's medical records revealed an admission date of 09/08/22. Diagnoses included dementia and need for personal care assistance. Review of the care plan dated 05/30/23 revealed Resident #272 was at risk for elopement related to dementia and impaired safety awareness. Interventions included observe for wandering, cue, reorient, and supervise as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #272 had impaired cognition. Resident #272 had wandering behaviors and required supervision with ambulation. Review of the progress note dated 06/17/23 revealed Resident #272 exited a secured unit after a nurse opened the door to the unit. Resident #272 was observed outside of the facility by a State Tested Nursing Assistant (STNA). 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 interview, observation, and record review the facility failed to ensure proper positioning of Resident #110's urinary catheter bag. This affected one resident (#110) of one resident observed for urinary catheters. The facility census was 124. Findings include: Review of Resident #110's medical record revealed an admission date of 05/01/23. Diagnoses included dementia, altered mental status, need for personal care assistance, and muscle weakness. Review of the care plan dated 05/01/23 revealed Resident #110 had a urinary catheter for elimination. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had impaired cognition, had a urinary catheter, and was incontinent of bowel. Observation on 08/14/23 at 10:05 A.M. revealed Resident #110 was resting in bed. The resident's urinary catheter bag was on the floor visible from the door. Interview with State…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide adequate pain management to Resident #110. This affected one resident (#110) of one resident reviewed for pain management. The facility census was 124. Findings include: Review of Resident #110's medical records revealed an admission date of 05/01/23. Diagnoses included dementia, muscle weakness, difficulty walking, and need for personal care assistance. Review of the care plan dated 05/01/23 (revised 07/11/23) revealed Resident #110 was at risk for pain related to a right femur fracture. Interventions included administer pain medications as ordered and give half an hour prior to treatment or care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had impaired cognition. Resident #110 required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. Review of the physician orders dated 07/17/23 to 08/09/23 revealed Resident #110 was ordered Tramadol (pain medication) 50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure adequate amounts of staff to provide timely and adequate resident care. This affected two residents (#14 and #46) of eight residents reviewed for staffing and had the potential to affect all 124 residents residing in the facility. Findings include: 1. Review of Resident #46's medical records revealed an admission date of 03/24/22. Diagnoses included dementia, muscle weakness, and difficulty walking. Review of the care plan dated 03/24/23 revealed Resident #46 required extensive assistance of one staff for toileting and personal hygiene. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had impaired cognition. Resident #46 required extensive assistance with toileting and personal hygiene and was incontinent of bowel and bladder. Interview on 08/14/23 at 9:35 A.M. with State Tested Nursing Assistant (STNAs) #69 and #101 revealed concerns related to staffing. STNAs #69 and #101 stated there were times there was only…

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.