Otterbein Sunset Village

Based on medical record review, observation and staff interview the facility to ensure call lights were with resident's reach. This affected one resident (#9) of one resident reviewed for call lights. The facility census was 47. Findings include: Review of the medical record for Resident #9 revealed an admission date of 07/27/17. Diagnoses included bipolar disorder, panic disorder, anxiety and epilepsy. Review of the care plan, revised October 2024, revealed Resident #9 was care planned for assistance with activities of daily living (ADLs) and fall risk with an identified intervention of call light in reach. Observation on 10/23/24 at 8:37 A.M. revealed Resident #9 was resting in bed and the call light was laying at the bottom of the bed, near the resident's feet, and not in reach of the resident. Interview on 10/23/24 at 8:48 A.M. with State Tested Nursing Assistant (STNA) #430 verified the call light was located at the foot of the bed by Resident #9's feet not in reach of the resident. STNA #430 further stated Resident #9 was able to use the call light and make her needs known.…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure the physician and responsible party were notified when medications were not administered as ordered by the physician. This affected one (#30) of one residents reviewed for notification of change of condition. The facility census was 47. Findings include: Review of Resident #30's medical record revealed an admission date of 01/10/24. Diagnoses included type II diabetes mellitus, non-pressure chronic ulcer of the heel and midfoot, neuromuscular dysfunction of bladder, benign prostatic hyperplasia, seizure disorder, coronary artery disease, depression, hypertension, peripheral vascular disease, malignant neoplasm of the head, face and neck, cerebral infarction, transient cerebral ischemic attack and history of venous thrombus and embolism. Review of the Minimum Data Set (MDS) assessment, dated 07/29/24, revealed Resident #30 was moderately cognitively impaired, had impaired range of motion to one upper extremity and required substantial to maximum (staff) assistance 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, medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented. This affected one resident (#9) of three residents reviewed for falls. The facility census was 47. Findings include: Review of the medical record for Resident #9 revealed an admission date of 07/27/17. Diagnoses included osteoarthritis, dementia, anxiety and bipolar disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed Resident #9 had some cognitive impairment. Review of the comprehensive fall risk assessment, dated 10/01/24, revealed Resident #9 was at risk for falls and had no falls in the past 90 days. Review of the care plan, revised October 2024, revealed Resident #9 was at risk for falls. Interventions included a fall mat. Observation on 10/21/24 at 10:23 A.M. of Resident #9 revealed she was in bed. A fall mat was leaning against the wall. Observation on 10/22/24 at 9:31 A.M. of Resident #9 revealed she was in bed. A fall mat was leaning against the wall. Interview on 10/22/24 at 10:32…

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 facility procedure, the facility failed to ensure medications were administered in a form as ordered by the physician, resulting in a medication error rate above five percent (%). This affected one (#37) of three residents observed during medication administration. A total of eight medication errors were observed out of 32 opportunities for a medication administration error rate of 25.00%. The facility census was 47. Findings include: Observation on 10/22/24 at 7:29 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #550 prepared medications for Resident #37. LPN #550 obtained the following medications from the medication cart: Amlodipine five milligram (mg), half tablet; Cholecalciferol 50 micrograms (mcg) tablet; Citalopram 40 mg tablet; Famotidine 20 mg tablet; Ferrous Sulfate 325 mg tablet; Magnesium Oxide 400 mg tablet; Senna-Docusate Sodium 8.6-50 mg, two tablets; and Calcium Citrate 950/200 mg, two tablets. LPN #550 proceeded to crush the tablets and placed them in applesauce,…

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, resident interview, staff interview and review of the Resident Council meeting minutes, the facility failed to ensure residents were provided with meals at an appetizing temperature. This affected two residents (#98 of #3) of seven residents who received food from the secured memory care unit serving kitchen but did not reside on the secured unit. The facility census was 47. Findings Include: Interview on 10/21/24 at 9:58 A.M. with Resident #98 revealed the resident was alert and aware. Resident #98 revealed she ate her meals in her room and by the time her meals got to her they were cold. Resident #98 stated the food did not taste good when it was cold. Interview on 10/21/24 at 10:06 A.M. with Resident #3 revealed the resident was alert and aware. Resident #3 revealed her only concern was the food served to residents in their rooms was always cold. Observation on 10/21/24 at 11:30 A.M. revealed the lunch meal cart was delivered to the serving kitchen on the secured memory care unit. Food temperatures were taken at 11:34 A.M. and the burger temperature was 150…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of immunization records, review of electronic mail (e-mail) communication, staff interview, review of facility policy and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered or administered pneumococcal vaccinations per CDC recommendations. This affected two (#22 and #30) of five residents reviewed for pneumococcal vaccination. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included unspecified diastolic heart failure, chronic kidney disease stage three, type two diabetes mellitus without complications and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated 07/14/24, revealed the resident was cognitively intact and the pneumococcal vaccine was not up to date. Review of the immunization record revealed Resident #22 last received the pneumococcal vaccine (PCV13) on 09/15/17. Review of vaccine consent…

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, medical record review, and review of the Diet Manual, the facility failed to provide a mechanically altered diet as ordered. This affected one (#15) of four residents (#12, #15, #16, and #17) who receive a mechanical soft diet. The facility census was 42. Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/23/22, with diagnoses of dementia and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition. Review of a physician order dated 09/06/22 revealed Resident #15 received a regular diet with mechanical soft textures and thin liquids. Review of the current care plan for Resident #15 she was at possible nutrition risk due to cognitive impairments, swallowing difficulty related to dysphagia, with need for altered texture diet. Interventions included providing the diet as ordered. Observation on 12/28/23 at 12:15 P.M., revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of policy, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when providing care to residents in Enhanced Barrier Precautions (EBP). This affected one (#14) of three residents reviewed for infection control. The facility identified ten current residents in EBP. The facility census was 42. Findings include: Review of medical record for Resident #14 revealed an admission date of 04/26/23 with a readmission on [DATE]. Diagnoses included hemiparesis (one-sided muscle weakness) and ulcer of the foot. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition and required substantial/maximal assistance with bathing and dressing. Review of a physician order dated 09/22/23 revealed Enhanced Barrier Precautions - gloves and gown with treatment and/or care two times a day for open wound area related to ulcer of foot. Review of a physician order dated…

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 and staff interview, the facility failed to ensure all staff working in the facility were aware of and trained on all available services, resources and treatment opportunities. This affected one (#45) of three residents reviewed for falls, with the potential to affect all residents of the facility. The facility census was 42. Findings include: Review of Resident #45's medical record revealed an admission date of 11/15/23 and discharge date of 11/27/23. Diagnoses included femur fracture, compression fracture of T5-T6 vertebra, osteoporosis and dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/21/23, revealed Resident #45 was cognitively impaired and required substantial/maximum assistance for bed mobility. Review of the plan of care, dated 11/16/23, revealed Resident #45 was at risk for falls. Interventions included to keep the bed low to the floor. Further review revealed on 11/15/23, a new intervention was added to place mats on the floor. Review of a nursing progress note, dated 11/15/23, revealed Resident #45 was found on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of an Emergency Medical Services (EMS) Run Report and staff interview, the facility failed to ensure timely and accurate documentation in the resident medical record. This affected one (#46) of of three reviewed for change in condition. The facility census was 42. Findings include: Review of Resident #46's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), diabetes, atrial fibrillation, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #46 was cognitively impaired and required moderate partial assistance for mobility. Review of a nursing progress note, dated [DATE], revealed resident expired at 6:45 P.M. at the facility. The family, management staff and on-call Nurse Practitioner (NP) were informed and Resident #46's body was released to the funeral home. No additional information…

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, observations, staff interview, review of the facility's policy, and review of Safety Data Sheets (SDS), the facility failed to ensure potentially hazardous chemicals were properly secured. This had the potential to affect nine residents (#2, #6, #8, #9, #14, #30, #33, #38, and #145) identified by the facility as being cognitively impaired and independently mobile and residing on the secured memory care unit. The facility census was 45. Findings include: Observation on 10/11/22 at 9:14 A.M. of the janitor closet on the secured memory care unit revealed the door was unlocked. Inside the closet was a 19-ounce can of furniture polish, approximately half full, with warnings indicating can be harmful and fatal; a full 42-ounce container of antibacterial hand wash; a 16-ounce half full container of laundry pre-spotter with warnings including caused severe skin burns and serious eye damage, may be corrosive to metal and keep out of reach; and lastly, a 32-ounce, one-third full, bottle of glass…

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, staff interview, and review of the facility's policy, the facility failed to ensure foods and beverages were properly stored, labeled and dated in the serving kitchen on the secured memory care unit. This had the potential to affect 19 of 19 residents residing on the secured memory care unit who received beverages from the kitchen. The facility census was 45. Findings include: Observation on 10/11/22 at 9:28 A.M. of the reach-in refrigerator in the serving kitchen on the secured memory care unit revealed an opened and undated half-full 46 ounce container of ready thickened cranberry juice cocktail; three squeeze bottles of various salad dressings, uncapped with dried salad dressing covering the openings, undated and unlabeled; one opened and undated 46 ounce container, approximately three - quarters full of apple juice; two opened and undated 46-ounce containers, each approximately one-third full, of apple juice; and a full half-gallon pitcher of an unknown liquid, unlabeled and undated. Additional observation of the reach in freezer revealed a slice of pie…

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, observations, resident interview, staff interview, and review of the facility's policy, the facility failed to ensure residents were treated with respect and dignity and had their care needs kept private. This affected one (Resident #15) of two residents reviewed for dignity. The facility census was 45. Findings include: Review of Resident #15's medical record revealed an admission date of 05/24/22. Diagnoses included kidney failure, anxiety disorder, and brief psychotic disorder. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Resident #15 required extensive assistance with bed mobility, transfer, toilet use and personal hygiene. Resident #15 displayed no behaviors during the review period. Observations on 10/11/22 at 8:22 A.M. of Resident #15's door to her room found a sign taped to the outside of the door alerting staff to Resident #15's hand washing care needs. The sign said Please remind…

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, observations, family and resident interview, and staff interview, the facility failed to ensure residents who required assistance from staff with activities of daily living received adequate and timely personal hygiene to promote promote proper hygiene and cleanliness. This affected two (Residents #3 and #36) of three residents reviewed for activities of daily living. The facility identified all 45 residents required assistance from staff with bathing and 44 residents required assistance from staff with dressing. The facility census was 45. Findings include: 1. Record review for Resident #3 revealed an original admission date of 09/03/21 and a readmission on [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarct, severe protein-calorie malnutrition, gastrostomy tube, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired. Resident #3 required limited assistance from staff 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 medical record review, staff interview, and review of the facility's policy, the facility failed to ensure resident weights were monitored according to dietician recommendations. This affected two (Resident #6 and #7) of three residents reviewed for nutrition. The facility identified five residents with a recent significant weight loss. The facility census was 45. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/08/21. Diagnoses included Alzheimer's disease, major depressive disorder, and schizoaffective disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired for daily decision making, rejected care, and had a wandering behavior. Resident #6 required limited assistance from staff with eating and had no significant weight loss. Review of the plan of care focus area, last revised on 09/29/22, revealed Resident #6 was at risk for changes to nutrition and hydration status…

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 the facility's policy, the facility failed to ensure anti-anxiety medications that were ordered as needed did not exceed the fourteen day limitation without physician rationale to continue the medication. This affected one (Resident #19) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include: Review of the medical record for Resident #19 revealed an admission date of 08/08/22 and a re-admission date of 09/08/22. Diagnoses included major depressive disorder and morbid obesity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was moderately cognitively impaired. Review of a physician order dated 08/18/22 revealed Resident #19 was ordered Ativan (medication used to treat anxiety) 0.5 milligrams (mg) one tablet by mouth every eight hours as needed for agitation. The order did not have an end date and was subsequently discontinued on 09/08/22, upon Resident #19's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure accurate medical records were kept for residents receiving dialysis. This affected one (Resident #15) of one resident reviewed for dialysis. The facility identified one resident who received dialysis. The facility census was 45. Findings include: Review of Resident #15's medical record revealed an admission date of 05/24/22. Diagnoses included kidney failure. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Resident #15 was receiving dialysis at the time of the review. Review of Resident #15's care plan revised 05/05/22 revealed supports and interventions for self-care deficit, risk for pain, and dialysis. Interventions for dialysis included to check/monitor for bruit and thrill each shift. Review of Resident #15's physician orders dated 08/20/22 revealed an order to complete pre-dialysis Communication Form in the electronic medical…

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 kitchen guidelines, and facility policy review, the facility failed to ensure hair restraints were worn appropriately, food surfaces were maintained in a sanitary manner, and food in the neighborhood kitchens were labeled and dated. This had the potential to affect 48 out of 48 residents who received meals from the kitchen or food items from neighborhood refrigerators. The facility census was 48. Findings include: 1. Observation on 10/07/19 at 10:02 A.M. revealed Culinary Staff #245 cutting fresh vegetables with a hair restraint covering only the top of the staff's head. The hair restraint was a disposable hairnet and the hairnet was placed at the hairline of the forehead to the top of the head covering less than a quarter of the staff's hair. The majority of Culinary Staff #245's hair was uncovered. Additional observation on 10/07/19 at 11:30 A.M. and 1:30 P.M. revealed Culinary Staff #245 in the kitchen with the hair restraint continued to be placed 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 and staff interview, the facility failed to ensure corridors were equipped with secured handrails on both side of the corridors. This had potential to affect 28 residents in the facility excluding 20 (#6, #10, #18, #20, #21, #22, #23, #24, #25, #29, #32, #33, #34, #38, #41, #42, #44, #45, #46, and #47) residents who reside on the secured unit. The census was 48. Findings include: Observation on 10/06/19 between 8:00 A.M. and 9:00 A.M., during the initial tour, revealed exit corridors throughout the facility. Observed on [NAME] Court revealed handrails were missing in the corridor outside room [ROOM NUMBER] and #27. Observation on [NAME] Court revealed hadrails were missing in the corridor outside room [ROOM NUMBER] and #25. Additionally, a handrail installed in the exit corridor leading from [NAME] Court to the therapy area was loose from the wall in three of the four installation points. On 10/09/19 between 7:30 A.M. and 8:00 A.M. measurements were obtained of the walls in the corridor on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, review of facility policy, observation, staff interview, and physician interview, the facility failed to timely notify the physician of a fall with a head injury for one (#22) out of two residents reviewed for falls. The facility census was 48. Findings include; Review of the medical record revealed Resident #22 admitted to the facility on [DATE]. Diagnoses included dementia, hypertension, osteoarthritis, Parkinson's disease, dysphagia, lack of coordination, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 08/21/19, identified the resident with mild cognitive impairment. The resident requires extensive physical assistance of one person for transfer, bed mobility and toileting and limited assistance of one person for mobility using a walker or wheelchair. The assessment also indicated the resident experienced a fall within the last month, with a history of falls, and fracture related to a fall in the six months prior to admission. Review of the fall…

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 and resident interview, review of facility Self-Reported Incident, review of a facility investigation, and review of a facility policy, the facility failed to follow their abuse policy for investigating and reporting allegations of misappropriation and injuries of unknown origin. This affected three (#8, #9, and #41) of three reviewed for abuse. The census was 48. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 07/23/18. Diagnoses included essential hypertension,. weakness, major depression, anxiety, malignant neoplasm of female breast, lymphedema, and unspecified macular degeneration. Review of the Minimum Data Set (MDS) assessment completed 07/19/19 revealed Resident #8 had moderate cognitive impairment. Review of Resident #9's medical record revealed an admission date of 07/23/18. Diagnoses included unspecified dementia without behavioral disturbances, weakness, unspecified convulsions, chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, observation, staff and resident interview, review of a facility investigation, review of facility Self-Reported Incidents (SRI)s, and review of a facility policy, the facility failed to report allegations of misappropriation and injuries of unknown origin to the appropriate staff member or designee, and failed to report such allegations to the state agency. This affected three (#8, #9, and #41) of three resident reviewed for abuse. The census was 48. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 07/23/18. Diagnoses included essential hypertension,. weakness, major depression, anxiety, malignant neoplasm of female breast, lymphedema, and unspecified macular degeneration. Review of the most recently completed Minimum Data Set (MDS) assessment completed 07/19/19 revealed Resident #8 had moderate cognitive impairment. Review of Resident #9's medical record revealed an admission date of 07/23/18. Diagnoses included unspecified dementia…

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

Based on medical record review, staff and resident interview, review of a facility investigation, and review of a facility policy, the facility failed to thoroughly investigate allegations of misappropriation. This affected two (#8 and #9) of three residents reviewed for abuse. This census was 48. Findings include: Review of Resident #8's medical record revealed an admission date of 07/23/18. Diagnoses included essential hypertension,. weakness, major depression, anxiety, malignant neoplasm of female breast, lymphedema, and unspecified macular degeneration. Review of the Minimum Data Set (MDS) assessment completed 07/19/19 revealed Resident #8 had moderate cognitive impairment. Review of Resident #9's medical record revealed an admission date of 07/23/18. Diagnoses included unspecified dementia without behavioral disturbances, weakness, unspecified convulsions, chronic obstructive pulmonary disease, and major depression. Review of the MDS assessment completed 07/17/19 revealed Resident #9 was severely cognitively impaired. Resident #8 and #9 were husband and wife Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure fall prevention interventions were consistently implemented for one (#22) of two residents reviewed for falls. The facility census was 48. Findings include: Review of the medical record revealed Resident #22 admitted to the facility on [DATE]. Diagnoses included dementia, hypertension, osteoarthritis, Parkinson's disease, dysphagia, lack of coordination, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 08/21/19, identified the resident with mild cognitive impairment. The resident requires extensive physical assistance of one person for transfer, bed mobility and toileting and limited assistance of one person for mobility using a walker or wheelchair. The assessment also indicated the resident experienced a fall within the last month, with a history of falls, and fracture related to a fall in the six months prior to admission. Review of the fall risk assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure physician visits were completed by a physician following admission and alternated between the physician and a nurse practitioner thereafter. This affected one (#29) of five residents reviewed for unnecessary medications. The census was 48. Findings include: Review of Resident #29's medical record revealed an admission date of 11/28/18. Diagnoses included unspecified dementia without behavioral disturbances, unspecified abnormality of gait and mobility, primary generalized arthritis, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severely impaired cognition. Review of physician and nurse practitioner visit notes revealed Resident #29 was initially seen by a nurse practitioner on 11/29/18. Subsequent visit notes dated 12/26/18, 01/09/19, 02/07/19, 02/20/19, 03/13/19, 04/17/19, 05/16/19, 06/13/19, and 07/11/19 revealed Resident #29 was only seen by a nurse…

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

Based on observation, review of the dietary spreadsheet, and staff interview, the facility failed to follow the menu for pureed diets by not serving bread to two (#10 and #18) of two residents receiving a puree diet. The facility census was 48. Findings include: Review of the dietary spreadsheet for a cheeseburger lunch meal for 10/07/19 lunch, revealed the puree diets were to receive a red scoop of pureed bread. Observation on 10/07/19 at 10:02 A.M. with [NAME] #218 revealed preparation of the pureed lunch. There was no pureed bread prepared. Observation on 10/07/19 from approximately 12:15 P.M. to 12:45 P.M. of the serving line revealed there was no bread option for residents with a pureed diet. Pureed diets were served to Resident #10 and Resident #18. Interview on 10/07/19 at 12:50 P.M., State Tested Nurse Aide (STNA) #233 verified Resident #10 and Resident #18 received the substitute cheeseburger meal and did not receive bread as indicated on the menu spreadsheet. STNA #233 stated the kitchen did not provide pureed bread and there was no substitute.