Kingston Health Center of Sylvania

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, the facility failed to monitor the use of psychotropic medications to confirm they were necessary. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The census was 122.Findings include:Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnosis that included insomnia. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/08/25, revealed the resident was cognitively intact. The assessment indicated Resident #4 had reported trouble falling asleep, staying asleep, or sleeping too much, on 12 to 14 days of the two-week assessment period.Review of Resident #4's physician orders revealed they included an order for trazodone hydrochloride (an antidepressant) 50 milligrams (mg) daily at bedtime, and an order for Ramelteon (a Melatonin receptor agonist) 8 mg daily at bedtime. Both orders were dated 11/02/25 and both orders specified the medications were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of policy for care planning, the facility failed to develop a care plan for a diagnosis of insomnia. This affected one resident (Resident #4) of 23 residents reviewed for care planning. The census was 122.Findings include:Review of Resident #4's medical record revealed the resident was admitted [DATE] and had diagnosis that included insomnia. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/08/25, revealed the resident was cognitively intact. The assessment indicated Resident #4 had reported trouble falling asleep, staying asleep, or sleeping too much, on 12 to 14 days of the two-week assessment period.Review of Resident #4's physician orders revealed they included an order for trazodone hydrochloride (an antidepressant) 50 milligrams (mg) daily at bedtime, and an order for Ramelteon (a Melatonin receptor agonist) 8 mg daily at bedtime. Both orders were dated 11/02/25 and both orders specified the medications were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received adequate activities of daily living care. This affected one Resident (#77) for toenail care and one Resident #72 for fingernail care. This had the ability to affect all residents. The facility census was 122.Findings include: 1. Review of Resident #77's medical record revealed an admission date of 11/07/26. Diagnoses included osteoarthritis, type II diabetes mellitus, and a history of lower leg cellulitis. Review of Resident #77's 5-day admission Minimum Data Set (MDS) dated [DATE] revealed the resident had an intake cognition. The resident required substantial assistance with rolling left and right and lying to sitting. Review of Resident #77's most recent care plan revealed the resident required assistance with activities of daily living related to weakness, low hemoglobin, and osteoarthritis in bilateral knees. Staff assistance was required 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, staff interview, resident review, and policy review, the facility failed to ensure nursing staff assessed wounds accurately. This affected Resident #123 and had the potential to affect 31 residents (#1, #6, #12, #15, #20, #27, #33, #36, #38, #49, #51, #57, #59, #68, #72, #87, #89, #95, #97, #99, #103, #104, #112, #120, #123, #124, #127, #129, #137, #140, and #141) identified with wounds. Additionally, the facility failed to ensure a resident did not receive food in preparation for a scheduled medical test. This affected one (#4) of one resident reviewed for medical testing. The facility census was 122. Findings include: 1. Review of the medical record for Resident #123 revealed an admission date of 04/12/15 with diagnoses of anxiety, chronic respiratory therapy, depression, embolism and thrombosis. Resident #123 was under the care of hospice. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/13/25, revealed Resident #123 had impaired cognition, was dependent on staff 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.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure pressure-reducing devices were in place. This affected two (#28 and #123) of six residents reviewed for skin breakdown. The facility census was 122.Findings include:1. Review of the medical record for Resident #28 revealed an admission date of 12/22/25 with diagnoses of atrial fibrillation, dementia, and Raynaud syndrome. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 12/29/25, revealed Resident #28 had impaired cognition and required substantial/maximal assistance for bed mobility. Further review revealed Resident #28 was at risk for developing pressure injuries.Review of the current care plan, initiated 12/22/25, revealed Resident #28 was at risk for impaired skin integrity, Interventions, initiated 12/23/25, revealed staff should off-load Resident #28's heels while in bed. Review of the physician order dated 12/23/25 revealed Resident #28 was to wear heel lift boots to both lower extremities when in bed. Observation on 01/05/26 at 2:07 P.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 observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure tube feedings were administered per the physician's orders and per professional nursing standards of practice. This affected one (#5) of one resident review for tube feeding. The facility census was 122.Findings include: Review of Resident #5's medical record revealed an admission date of 12/06/25. Diagnoses included hypertensive chronic kidney disease stage 3B, anxiety, non-ischemic myocardial injury, gout, and type two diabetes mellitus.Review of Resident #5's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated Resident #5 had severely impaired cognition. Furthermore, Resident #5 was dependent for eating and all mobility.Review of Resident #5's care plan with a date initiated of 12/06/25 revealed Resident #5 required a tube feeding to maintain adequate nutrition and hydration with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure medications were administered per physician orders. This affected one (#3) of seven residents reviewed for medication administration. The facility census was 122.Findings include:Review of the medical record for Resident #3 revealed an admission date of 12/01/25 with diagnoses of hypertensive heart disease and chronic kidney disease, dementia, and heart failure. Resident #3 discharged home on [DATE].Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 12/08/25, revealed Resident #3 had impaired cognition and received antipsychotics, and antianxiety and antidepressant medications. Review of the physician order initiated 12/01/25 and discontinued upon discharge on [DATE], revealed Resident #3 received Lisinopril (a blood pressure lowering medication) oral tablet 40 milligrams (mg), one tablet daily for hypertension; hold for SBP (systolic blood pressure) less than 100 millimeters of Mercy…

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

Based on observation, medical record review, staff interview, and review of policy for medication storage, the facility failed to label insulin injector pens with open dates. This affected three residents (Residents #5, #20, and #148). The facility identified 22 residents with current orders for insulin injections. Further, the facility failed to properly store medications during the medication administration process. This affected one resident (Resident #20) of four residents observed during medication administration. The census was 122.Findings include: 1. Review of Resident #5's medical record revealed an admission date of 12/06/25 with diagnoses that included type II diabetes mellitus. Review of Resident #5's physician orders revealed they included an order for insulin Glargine (Lantus) solution via pen injector, inject 35 units every 12 hours for diabetes. Observation on 01/12/26 at 10:47 A.M. of the C-2 Hall medication cart, revealed it contained an insulin Glargine pen injector for Resident #5, with approximately 70 units of insulin remaining. The pen injector was not marked…

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 medical record review, staff interview, review of facility submitted Self-Reported Incidents (SRI), review of personnel records, and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident abuse. This affected one (#108) of three residents reviewed for abuse. The facility census was 117.Findings include:Review of the medical record revealed Resident #108 was admitted on [DATE]. Diagnoses included unspecified dementia moderate with other behavioral disturbances, chronic kidney disease stage two, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and dysphagia oropharyngeal phase.Review of the Minimum Data Set (MDS) assessment, dated 08/19/25, revealed the resident was severely cognitively impaired and required substantial assistance with chair to bed transfers. Review of nursing progress note, dated 09/23/25…

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

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 medical record review, staff interview, review of a facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure staff timely reported allegations of abuse. This affected one (#108) of three residents reviewed for abuse. The facility census was 117.Findings include:Review of the medical record revealed Resident #108 was admitted on [DATE]. Diagnoses included unspecified dementia moderate with other behavioral disturbances, chronic kidney disease stage two, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and dysphagia oropharyngeal phase.Review of the Minimum Data Set (MDS) assessment, dated 08/19/25, revealed the resident was severely cognitively impaired and required substantial assistance with chair to bed transfers. Review of a nursing progress note dated 09/23/25 at 7:15 A.M. revealed a bruise was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a sanitary and comfortable environment. This affected 18 (Residents #75, #1, #7, #47, #53, #54, #55, #60, #65, #66, #69, #74, #78, #102, #104, #109, #114, and #115) of 18 residents reviewed. The facility census was 126. Findings include: 1. Review of the medical record for Resident #75 revealed an admission date of 02/12/25 with diagnoses including displaced fracture of neck of right radius, fracture of left pubis, fracture of right pubis, Parkinson's disease, depression, osteoporosis, and urge incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #75 was cognitively intact. Observation on 03/10/25 at 9:57 A.M. of Resident #75's room revealed there were three spots on the floor that were sticky and scattered debris on the floor. Interview on 03/10/25 at 10:00 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 observation, staff interview, review of maintenance work orders, review of call light logs and review of policy, the facility failed to maintain a functional call light system. This affected six (#37, #38, #44, #59, #78, and #108) with the potential to affect all 105 residents in a facility. The total facility census was 105. Findings include: Observation on 10/24/24 at 4:20 A.M., revealed the green light above Resident #38's room was illuminated. Interview on 10/24/24 at 4:20 A.M., with Licensed Practical Nurse (LPN) #207 revealed the green light above each resident room is intended to illuminate when a member of therapy staff is in the room with the resident. Observation on 10/24/24 at 4:22 A.M., revealed Resident #38 was asleep in her room with no therapy staff present. Interview on 10/24/24 at 4:23 A.M., with LPN #207 verified the light was green above the door but no staff were in the room. Observation on 10/24/24 at 5:27 A.M., revealed the green light above Resident #38's room continued to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, resident interview, and review of the facility policy, the facility failed to provide adequate supervision and assistance during resident care, resulting in the resident falling out of bed. This affected one (Resident #87) of three residents reviewed for falls. The facility census was 112. Findings include: Review of the medical record for Resident #87 revealed an admission date of 11/13/23. Diagnoses included quadriplegia and left lower leg amputation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intake and dependent on staff for all care. The resident suffered impairment to bilateral sides of his upper and lower body. Review of Resident #87's most recent care plan revealed the resident was at risk for falls due to quadriplegia. Review of Resident #87's Fall Risk Evaluation dated 06/01/24 revealed he was at a high risk for falls. Review of the nurse's note dated 06/01/24 revealed Resident #87 fell out of bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the facility was free from significant medication errors when an antibiotic was not administered as ordered for one (#3) of five residents reviewed for medication administration in a facility census of 112. Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included hypotension, chronic kidney disease, atrial fibrillation, coronary artery disease, dementia, benign prostatic hyperplasia, congestive heart failure, and ischemic cardiomyopathy. Review of the physician order dated 07/12/23 revealed an order for the administration the antibiotic cephalexin 500 milligrams (mg) every morning and at bedtime for cellulitis to the toe for 10 days. Review of the medication administration record noted the cephalexin 500 mg to be documented as administered twice on 07/13/23 twice and once in the morning on 07/14/23. Beginning with the 07/14/23 evening dose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents were provided with clean linen. This affected one (Resident #70) of three residents reviewed for a clean and sanitary environment. The facility census was 113. Findings include: Review of the medical record revealed Resident #70 was admitted on [DATE]. Diagnoses included localization related symptomatic epilepsy and epileptic syndromes with complex partial seizures, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, major depressive disorder, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Review of the progress note dated 06/01/23, revealed Resident #70 had a mole noted to his back area. There was bloody drainage coming from under the mole. The physician provided a one time treatment ordered and advised the mole would be removed the next day.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure a resident's personal hygiene needs were met. This affected one (Resident #58) of one resident reviewed for activities of daily living. The facility census was 113. Findings include: Review of the medical record revealed Resident #58 was admitted on [DATE]. Diagnoses included peripheral vascular disease, dementia in other diseases classified elsewhere, type two diabetes mellitus with diabetic chronic kidney disease, Parkinson's disease, hyperlipidemia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #58 was moderately cognitively impaired and required extensive one person assistance with dressing and personally hygiene and extensive two person assistance with bed mobility, dressing, and toilet use. Resident #58 required two person total dependence for transfers and total dependence one person for locomotion on and off…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure auto-lock brakes were applied to a resident's wheelchair as ordered to potentially prevent falls. This affected one (Resident #41) of three residents reviewed for falls. The facility census was 113. Findings include: Review of Resident #41's medical record revealed an admission date of 08/13/20. Diagnoses included Alzheimer's disease, respiratory failure, type II diabetes mellitus, heart disease, heart failure, history of falling, and dysphagia. Review of Resident #41's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident was cognitively impaired. The resident required extensive assistance of two staff for the majority of activities of daily living. Review of Resident #41's active physician orders identified an order dated 01/03/23 for auto-lock brakes to wheelchair. Review of Resident #41's plan of care dated 09/05/20 and revised 03/21/23, revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, facility pain clinical protocol and manufacture owners manual, the facility failed to ensure pain control interventions were monitored for effectiveness. This affected one resident (#52) reviewed for pain control interventions. Facility census 113. Findings include: Medical record review revealed Resident #52 admitted to the facility on [DATE] with diagnoses including, cerebral infarction with hemiplegia and hemiparesis affecting left non-dominant side, hypertension, anxiety, osteoporosis, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact, dependent on staff for the completion of activities of daily living, dependent on staff for bed mobility and transfer, and received as needed pain medications. Further review of the medical record revealed on 05/08/23, a nursing plan of care was implemented to address Resident #52's pain related to osteoporosis. Interventions included 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 2. Observation on 02/26/20 at 5:18 P.M. revealed DM #500 was in the kitchen cooking at the stove, and plating food for hall trays. DM #500 had a hair net on, however did not have her bangs and approximately two inches of the front of her hair covered. Interview with DM #500 at the time of the observation verified the hair nets were required in the kitchen and her hair was not fully covered. Review of the facility policy titled Dietary Infection Control approval date April 2014 revealed hair restraints are required and should cover all hair. 3. Observation on 02/24/20 at 12:29 P.M. of hall trays being served by State Tested Nursing Assistant (STNA) #587 to room [ROOM NUMBER] revealed she assisted the resident with set up of her food tray with bare hands touching several surfaces on, and around the tray. The STNA touched several personal items of the resident in assisting the resident to reposition to eat more comfortably. STNA #587 did not do any hand hygiene before leaving room [ROOM NUMBER]. The STNA #587 went…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the State Agency. This affected one Resident (#39) of one reviewed for abuse. The facility census was 123. Findings include: Medical record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, quadriplegia, and chronic diastolic congestive heart failure. Review of Resident #39's progress note dated 02/16/20 revealed Resident #39 reported to his brother a State Tested Nursing Assistant (STNA) threatened to harm him. Resident #39's brother called the facility and reported the allegation to Registered Nurse (RN) #625. There was no evidence RN #625 reported the allegation to the Administrator. There was no evidence the facilty reported the allegation to the state agency. Interview on 02/26/20 at 6:11 P.M. with the Administrator verified he was not aware an allegation of staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure an allegation of staff to resident verbal abuse was thoroughly investigated. This affected one Resident (#39) of one reviewed for abuse. The facility census was 123. Findings include: Medical record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, quadriplegia, and chronic diastolic congestive heart failure. Review of Resident #39's progress note dated 02/16/20 revealed Resident #39 reported to his brother a State Tested Nursing Assistant (STNA) threatened to harm him. Resident #39's brother called the facility and reported the allegation to Registered Nurse (RN) #625. There was no evidence RN #625 reported the allegation to the Administrator. There was no evidence the facilty reported the allegation to the state agency. Interview on 02/26/20 at 6:11 P.M. with the Administrator verified he was not aware an allegation of staff to 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 3. Medical record review revealed Resident #78 was admitted to the facility on [DATE]. Review of Resident #78's MDS assessment dated [DATE] revealed the resident was cognitively intact. Continued review of Resident #78's medical record revealed the resident was transferred to the local hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence the resident received a copy of the facility's bed hold policy. Interview on 02/27/20 at 8:32 A.M. with the Director of Nursing (DON) verified there was no evidence Resident #78 was provided a copy of the facility's bed hold policy. Review of the facility policy titled, Bed Hold, Transfer, and Discharge Notice, approval date of September 2018 revealed at the time of transfer to an acute care facility (hospital) or as soon as practicable the resident and their representative will be issued transfer notice for Ohio facilities, or the notice of transfer discharge. A bed hold notice was required at the time of transfer or in the case of emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to develop a plan of care for the use of a Foley catheter for one Resident (#105) of 24 reviewed for care plans. The facility census was 123. Findings include: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The resident was noted to be admitted to the facility with an indwelling Foley catheter in place. Review of the comprehensive plan of care revealed revealed there was no care plan in place for catheter care for Resident #105. Review of the physician orders revealed the Foley catheter was discontinued for Resident #105 on 02/11/20, and to check post-void residual every eight hours, for 72 hours. On 02/14/20 a physician order revealed to restart the Foley catheter. Interview with the Director of Nursing (DON) on 02/26/20 at 10:30 A.M. verified Resident #105 had a Foley Catheter in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, resident interview, and facility policy review, the facility failed to provide an individualized activity program designed to meet the interests and social needs of nonverbal residents. This affected one Resident (#63) of one reviewed for activities. The facility census was 123. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, aphasia, and dementia. Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. Resident #63 was totally dependent on staff for transfer, and locomotion. Review of Resident #63's care plan revised 01/22/20 revealed supports and interventions included to pursue independent activity daily, such as television, radio, visits, and reading (large print as needed). In addition Resident #63 was to attend group activities of interest, such as, church services,…

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 test tray tasting, staff interview, resident interview, and review of facility policy, the facility failed to serve food that was palatable and appealing. This affected one Resident (#215) of six reviewed for food quality. The facility census was 123. Findings include: A test tray completed on 02/26/20 at 5:54 P.M. revealed the dinner meal consisted of chicken stir fry over rice with snap peas. The stir fry vegetables were unidentifiable and mushy. The snap peas were mushy and gray. The presentation was unappealing, grayish, and brownish in color. The temperature of the food was warm, not hot. The snap peas tasted bland with no seasoning, and the consistency was mushy. The chicken stir fry was salty. The test tray was sampled by two state surveyors and the Assistant Director of Nursing (ADON) #707. The ADON verified the snap peas were bland and mushy. Interview with Resident #215 on 02/27/20 at 10:16 A.M. verified she had the chicken stir fry with rice and snap peas for the dinner meal on 02/26/20. Resident #215 stated the snap peas were not good and she did not eat them.…

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

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to maintain infection control practices during a dressing change. This affected one Resident (#214) of three reviewed for pressure ulcers. The facility census was 123. Findings include: Review of the medical record for the Resident #214 revealed an admission dated of 02/06/20 with diagnoses including acute kidney failure, congestive heart failure, type two diabetes, dependence on renal dialysis, and peripheral vascular disease (PVD). Review Resident #214's pressure injury review dated 02/06/20 revealed an unavoidable stage two pressure ulcer of the right lateral heel. Observation on 02/26/20 at 12:15 P.M. with the Assistant Director of Nursing (ADON) of the right lateral heel dressing change for Resident #214 revealed after removing the old dressing and cleaning the wound, the ADON placed the Resident #214's uncovered right heel on the bed. The ADON left the room to check the dressing change order, returned to the room, completed hand hygiene, and paced a dressing over…

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.