The Colony Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure staff treated Resident #109 with dignity and respect. This affected one resident (#109) out of three residents reviewed for abusive treatment in the facility. The facility census was 108. Findings include: Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, restlessness, depression, insomnia, malnutrition, asthma, anorexia, high blood pressure, kidney failure, spondylosis, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 had severe cognitive impairment, had behaviors including wandering and refusing care, and was independent with transfers and ambulation. Resident #109's plan of care initiated on 05/03/24 indicated a risk for falls related to impaired cognition related to diagnosis of Alzheimer's disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #83's sponsor was notified of significant changes in Resident #83's condition. This affected one resident (#83) out of three residents reviewed for changes in condition. The facility census was 108. Findings include: Review of the medical record revealed Resident #83 was admitted on [DATE] with diagnoses including cerebral vascular disease, vascular dementia pulmonary disease, high blood pressure, atherosclerotic heart disease, hyperlipidemia, iron deficiency anemia major depressive disorder, insomnia, osteoporosis, diaphragmatic hernia, gastroesophageal reflux disease with esophageal obstruction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had a significant change in her ability to sit up from a lying down position and from sitting to standing. The MDS assessment dated [DATE] indicated she was independent in the ability to sit up from a lying down position and from sitting…

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, interview, and policy review, the facility failed to ensure all medications were stored and labeled as required. This affected five (Residents #47, #48, #49, #50, #51) of 10 residents reviewed. Findings include: Observation on 03/14/24 at 7:37 A.M. revealed Licensed Practical Nurse (LPN) #216 had pre-poured medications for Residents #47, #48, #49, #50, #51. A drawer within the medication cart contained five medication cups each containing medications with the resident's name. There was no information regarding the names or strength of the medications in the cups. Interview with LPN #216, at the time of the observation, revealed the medications were pre-poured because he was required to be in the dining room from 7:30 A.M. to 9:00 A.M. to observe residents during breakfast and he had more than 30 residents to administer medications to after breakfast service was finished. Review of the facility's undated policy titled Medication Administration revealed medications were to be poured just prior to administrating to the resident.

Based on observation, interview, and policy and procedure review, the facility failed to ensure staff maintained infection control standards when administering medications. This affected one (Resident #47) of five residents observed for medication administration. Findings include: Observation on 03/14/24 at 8:13 A.M. revealed Licensed Practical Nurse (LPN) #216 preparing medications to administer to Resident #47. LPN #216 popped medications from blister packs into his bare hand and then picked up medications that were dropped and put them into a medication cup to administer to Resident #47. An interview with LPN #216 at the time of the observation confirmed the observations. Review of the facility's undated policy titled Medication Administration revealed medications were not to be touched, either when opening a liquid or dose pack. Dropped medications were to be discarded.

Based on record review and interview the facility did not ensure the activity director was qualified to establish and provide a therapeutic activity program to meet the needs and interests of the resident population in the facility. This affected all 110 residents living in the facility. Findings include: Review of the employee file for Activity Director (AD) #805 revealed a hire date of 03/28/23 with a signed job description dated for 03/28/23. As stated in the Purpose/Belief statement the position of the AD establishes an activity program of wide variety for the residents, enhancing the resident's wellness, in harmony with the overall plan of care set forth by the health care team, and in accordance with state and federal regulations. This position plans, implements, supervises and supports all operations of the activities department. While focusing on delivery of quality care, the position must also manage the assigned resources. As listed in the Qualifications/Knowledge/Skills and Abilities section, the AD role requires either a bachelor's degree in therapeutic recreation or…

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

Based on observation and interview, the facility failed to ensure dietary staff were competent to complete their duties. This had the potential to affect all 109 residents who received meals from the kitchen except one resident (Resident #98) who the facility identified as eating nothing by mouth. The census was 110. Findings include: Review of the staff on-boarding packets for all dietary staff hired within the last six months revealed three staff (Cook #818, Dietary Aide #819, and State Tested Nurse Aide [STNA] #869) answered the on-boarding quiz questions incorrectly despite the correct answers being listed immediately following the questions. On 10/16/23 at 8:42 A.M., observation of the kitchen revealed food was stored on the floor in the walk-in refrigerator, walk-in freezer, and dry storage. On 10/16/23 at 8:58 A.M., interview with Dietary Aide #824 stated new staff did not get the appropriate training to know how to put away food items after they were delivered to the facility. On 10/18/23 at 11:20 A.M., observation of the lunch meal tray line revealed four residents (#6,…

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, interview, review of facility policy, and review of the Ohio Uniform Food Safety Code, the facility failed to ensure food items were stored at least six inches off the floor. This had the potential to affect all 109 residents who received food from the kitchen and excluded Resident #98 who received nothing by mouth. The census was 110. Findings include: On 10/16/23 at 8:42 A.M., observation of the kitchen revealed a crate containing 12 cartons of milk was on the floor of the walk-in refrigerator, one box of chopped spinach was on the floor of the walk-in freezer, and the following items were observed on the floor of the dry storage room: one box of pasta, one case containing 12 cans of tomato juice, one box of cranberry juice, one box containing 150 packets of hot cocoa mix, and one box containing three gallons of pancake and waffle syrup. On 10/16/23 at 8:58 A.M., interview with Dietary Aide #824 verified the multiple boxes of food items that were on the floor of the dry storage room. Dietary Aide #824 stated new staff did not get the appropriate training 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.

Based on observation, record review and interviews, the facility administrator did not ensure a qualified activity director was hired to administer a therapeutic activity program to meet the needs and interests of the residents. This had the potential to affect all 110 residents living in the facility. Findings include: Review of the position description for the executive director, signed by the Administrator on 11/23/2020, revealed it was the Administrator's responsibility to provide leadership to all staff to ensure care standards were met in accordance with state and federal regulations and the highest degree of quality resident care was provided at all times. Review of the employee file for the Activity Director (AD) #805 revealed a hire date of 03/28/23 with a signed job description dated for 03/28/23. It was stated in the AD job description her direct report was the Administrator. As listed in the Qualifications/Knowledge/Skills and Abilities section the AD role required either a bachelor's degree in therapeutic recreation or related field or 90 hour course for activity…

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

Based on review of the resident council meeting minutes and resident and staff interviews, the facility failed to ensure ongoing communication to residents about their various rights at the resident council meetings. This affected 15 residents (Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) of 15 residents present at the resident council meeting. The facility census was 110. Findings include: Review of the facility Resident Council Meeting minutes from January 2023 to October 2023 revealed there was not a new resident right reviewed at each meeting. Meetings conducted on 01/30/23 revealed they reviewed smoking rights. Meetings conducted on 02/24/23, 04/13/23, 05/18/23, 06/15/23, and 07/20/23 revealed they reviewed the right to have resident council meetings. Meetings conducted on 08/17/23, 09/21/23 and 10/05/23 revealed they did not review any resident rights during the council meetings. Interview on 10/17/23 at 4:15 P.M. with Activities Director (AD) #805 revealed she was unaware she was to review a different resident right at each…

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

Based on record review, observations and interviews the facility failed to provide therapeutic activities as scheduled on the activity calendar and failed to provide evening activities to meet the needs and preferences of all the residents in the facility. This affected 15 residents (#12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) residing on the A,B and C units and had the potential to affect all residents residing on the A, B, C units excluding Residents #16, #41, #264, #80, #2, #77, #45, #39, #66, #15, #42, #74, #89, #38, #86, #35, #37, #90, #91, #69, #93, #92, #75, #97 and #6 who resided on the secured unit D. The facility census was 110. Findings include: Review of the facility activity calendars for October 2023 for the A, B, and C units, revealed on all 31 days in October 2023, the last activity was scheduled at 4:00 P.M., and no evening activities were offered during the month. The scheduled activities for 9:30 A.M. included coffee and chit chat. On Sunday the activity was listening to gospel music at 10:30 A.M. and church service and music…

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. Resident #80 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorder, anxiety, congestive heart failure, chronic obstructive pulmonary disease, and major depression. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment, dated 10/04/23, revealed the resident was moderately cognitively impaired and exhibited no behaviors. Review of the physician's orders revealed Resident #80 was receiving an antipsychotic medication for a diagnosis of delusional disorder. Review of the August, September and October 2023 Medication Administration Record (MAR) for Resident #80 for behavior monitoring revealed the resident had four days with behaviors in October, and no behaviors were exhibited in September or August. Review of the State Tested Nursing Assistants (STNA) behavior monitoring for Resident #80 for the past 30 days revealed the resident exhibited no behaviors. Review of the nursing progress notes revealed no behaviors were observed from August through…

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, interview, record review, and review of facility policy, the facility failed to ensure resident food preferences were honored. This affected three residents (#14, #24, and #94) of five residents reviewed for food and nutrition. The census was 110. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 05/18/23 with diagnoses including type two diabetes, chronic kidney disease, congestive heart failure, and chronic obstructive pulmonary disease. Review of the nutrition care plan, revised 08/10/23, revealed Resident #14 had the potential for altered nutrition status due to type two diabetes, chronic kidney disease, hypertension, lymphedema, chronic obstructive pulmonary disease, altered skin integrity, and therapeutic diet. Interventions included identify resident food and beverage preferences, and monitor meal intake, Review of the physician's orders for October 2023 identified orders for a controlled carbohydrate diet with regular texture and thin liquid consistency. Review of the quarterly Minimum Data Set (MDS)…

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

Based on record review, interview, and review of facility policy, the facility failed to provide snacks per resident preferences and the plan of care. This affected seven (#12, #51, #62, #67, #71, #79, and #85) of seven residents reviewed for snacks and had the potential to affect all residents (except Resident #98) residing in the facility. The census was 110. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 05/05/23 with diagnoses including end stage renal disease, dependence on renal dialysis, congestive heart failure, major depressive disorder, type two diabetes, and gastroesophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/31/23, revealed Resident #12 had intact cognition. Review of the nutrition care plan, revised 08/04/23, revealed Resident #12 had the potential for altered nutritional status due to end stage renal disease dependent on hemodialysis, type two diabetes, gastroesophageal reflux disease, hypertension, fatty liver, congestive heart failure, obesity, anemia, diverticulosis,…

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, record review, and policy review, the facility did not ensure the authorized parties were notified of changes in the resident's treatment for Resident #15 and Resident #19. This affected two residents (Residents #15 and #91) of 26 residents reviewed for notification of change. The facility census was 110. Findings Include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Resident #15's family member was listed as the authorized primary contact. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the physician's orders revealed on 09/11/23 Resident #15 was started on Macrobid (an antibiotic) 100 milligrams (mg) twice a day for a urinary tract infection (UTI). Review of the nursing progress notes revealed no documentation 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 staff interview and record review the facility failed to ensure resident assessments were accurate. This affected two residents (Residents #15 and #40) of 26 residents reviewed for resident assessments. The facility census was 110. Findings Include: 1. Review of the medical records revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Review of the nursing progress notes for Resident #15 from admission through the present revealed on 09/06/23 the resident had increased confusion, wandering, exit seeking, agitation, and believed others were stealing her belongings. No other behaviors were documented. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired and exhibited the behavior of wandering for one to three days during the assessment period.…

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, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident who was dependant on staff for assistance with activities of daily living (ADLs) received the assistance needed with bathing and personal hygiene. This affected one resident (Resident #68) of two residents reviewed for ADLs. The facility census was 110. Findings include: Review of the medical record for Resident #68 revealed he was admitted on [DATE] with diagnoses including alcohol-induced dementia, myoclonus, anorexia, osteoarthritis, and lack of coordination. Review of Resident #68's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition with no signs or symptoms of delirium. Further review of the MDS revealed Resident #68 was dependent for bathing and required one person assistance with locomotion, dressing, eating, toileting, personal hygiene. The MDS further revealed Resident #68 had no instances of rejecting care. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review and interview, the facility failed to properly assess and document skin concerns for Resident #363. This affected one resident (#363) out of five residents reviewed for skin concerns. The facility census was 110. Findings include: Review of the hospital discharge reconciliation report dated 12/12/22 revealed Resident #363 was ordered collagenase (removes damaged tissue from skin ulcers) to left planter foot daily and as needed with last administered date of 12/11/22 at 9:10 A.M. Review of the medical record revealed Resident #363 was admitted on [DATE] and discharged on 12/23/22 with diagnoses including chronic kidney disease, fracture of cervical vertebras, type two diabetes mellitus, chronic obstructive pulmonary disease, methicillin susceptible staphylococcus aureus, end stage renal disease, sarcoidosis, neuromuscular dysfunction of bladder, and neurogenic bowel. A nurse note dated 12/16/22 at 6:11 P.M. revealed Resident #363 was admitted with no open skin areas and his…

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 interviews, the facility failed to ensure residents received hearing supports and devices in a timely manner. This affected one resident (#24) of one resident reviewed for hearing ancillary services. The census was 110. Findings include: Review of the medical record for Resident #24 revealed an admission date of 04/19/21 with diagnoses including alcohol dependence, schizoaffective disorder, emphysema, and post-traumatic osteoarthritis of his right hip. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact with minimum hearing difficulty. No hearing appliance was used in the conduction of this assessment. Further review of the MDS revealed Resident #24 exhibited no behaviors and had no rejection of care. Review of Resident #24's care plan revealed he had difficulty hearing, had hearing aids, and did not always choose to wear his hearing aids. Interventions included ensuring hearing aids were in place, observing…

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 a thorough investigation to identify and analyze hazards and risk factors for falls was conducted regarding falls for Resident #15, #94 and #102. This affected three residents (Resident #15, #94, and #102) of five residents reviewed for falls. The facility census was 110. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired and had hallucinations and delusions. The resident was identified as having a fall with major injury. Review of the care plans for Resident #15 revealed the falls care plan was initiated on 08/28/23. The interventions implemented at that time included to assess fall risk on admission,…

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 ensure a physician's order was obtained for oxygen administration. This affected one resident (Resident #54) of three residents reviewed for oxygen therapy. The facility identified six other residents (Residents #13, #17, #34 #57, #67 and #79) identified by the facility as using oxygen therapy. The facility census was 110. Findings include: Review of the medical record for Resident #54 revealed an admission date of 05/10/22 with diagnoses including end stage kidney disease, diabetes, chronic obstructive pulmonary disease (COPD) and arthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #54 was totally dependent on two people for transfers, required extensive assistance of two people for bed mobility, dressing and toilet use and extensive assistance of one person for hygiene. She did not receive oxygen therapy. Review of the physician's orders for October 2023…

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 a physician's order was obtained for dialysis treatment for two residents (Residents #51 and #102) and that pre and post dialysis assessments were completed for Residents #40, #51 and #102. This affected three residents (#40, #51 and #102) of three residents reviewed for dialysis treatment. The facility census was 110. Findings include: 1. Review of the medical record revealed resident #40 was admitted to the facility on [DATE] with diagnoses including end stage renal disease dependent on dialysis. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the physician's orders for October 2023 revealed Resident #40 received dialysis three days a week. Review of the pre and post dialysis assessments since admission revealed no pre-dialysis assessments were completed on 08/07/23, 08/11/23, 08/16/23, 08/21/23, 08/23/23, 08/28/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview, the facility failed to provide medication as ordered for Resident #363. This affected one (Resident #363) out of five residents reviewed for medications. The facility census was 110. Findings include: Review of the medical record revealed Resident #363 was admitted on [DATE] and discharged on 12/23/22 with diagnoses including chronic kidney disease, fracture of cervical vertebras, type two diabetes mellitus, chronic obstructive pulmonary disease, methicillin susceptible staphylococcus aureus, end stage renal disease, sarcoidosis, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of physician orders dated 12/16/23 at 8:20 P.M. revealed Resident #363 was ordered Oxycodone (narcotic for moderate to severe pain) 20 milligrams (mg) every six hours for pain and Oxycodone 20 mg every three hours as needed for pain. Review of medication administration note dated 12/17/22 at 2:59 P.M. revealed Oxycodone was not administered due to waiting on prescription 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, observation, and interview the facility failed to ensure insulin was given per physician's orders. This affected one resident (Resident #362) of six residents reviewed for medication administration. The facility census was 110. Findings include: Medical record review for Resident #362 revealed an admission date of 10/05/23 with diagnoses including type two diabetes mellitus with hyperglycemia and diabetic neuropathy, morbid obesity with alveolar hypoventilation, pulmonary hypertension, depression, and cerebrovascular disease. Review of Resident #362's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had moderately impaired cognition. She was independent with eating and personal hygiene and required set-up or clean-up assistance with bathing and dressing her lower body. Mobility devices included a wheelchair and a walker, and she required supervision with transfers. Review of physician orders for Resident #362 revealed an order dated 10/06/23 for five units 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, observation, and interview the facility failed to ensure medications were stored and labeled in a manner that prevented the risk of residents receiving insulin that belonged to another resident. This affected one resident (Resident #362) of six residents reviewed for medication administration. The facility census was 110. Findings include: Medical record review for Resident #362 revealed an admission date of 10/05/23 with diagnoses including type two diabetes mellitus with hyperglycemia and diabetic neuropathy, morbid obesity with alveolar hypoventilation, pulmonary hypertension, depression, and cerebrovascular disease. Review of Resident #362's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had moderately impaired cognition. She was independent with eating and personal hygiene and required set-up or clean-up assistance with bathing and dressing her lower body. Mobility devices included a wheelchair and a walker, and she required supervision with transfers.…

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, and interviews the facility failed to provide restorative nursing services to Resident #14, Resident #37, Resident #38, Resident #37, Resident #50, and Resident #57. This affected six (Resident #14, Resident #37, Resident #38, Resident #37, Resident #50, and Resident #) of six residents reviewed for restorative nursing programs. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses including unspecified abnormalities of gait and mobility and other intellectual disabilities. Resident #14's physician order dated 12/09/2020 revealed the resident was to receive skilled physical therapy (PT) services five times a week for four weeks, focusing on therapeutic exercise, therapeutic activity, mobility, transfers, gait, activity tolerance, safety awareness, falls prevention, and patient education. Review of Resident #14's Physical Therapy Discharge summary dated [DATE] revealed the resident had a good prognosis to maintain his current level 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 observation, interview and record review the facility failed to accurately obtain, monitor and assess weight changes for Residents #22, #30, #44, #50 and #58. This affected five residents (Residents #22, #30, #44, #50 and #58) of seven residents reviewed for nutrition. Findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnosis of psychosis, type II diabetes, and dysphagia. Review of Resident #44's quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment, had a mechanically altered diet, needed setup for eating, and had a weight loss of 5% or more in the last month or weight loss of 10% or more in last six months, and was on an unprescribed weight loss regimen. Review of Resident #44's weights revealed the resident sustained a weight loss between 01/01/2021 (179.5) and 02/01/2021 (148.2) of 31 pounds. This triggered a weight warning in the computerized charting and a re-weigh was request on 02/02/2021.…

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 ensure the resident narcotics on the controlled drug administration records were signed off in a timely manner for Resident #3, #22, #30, #50, #51, #63 and #68 and failed to ensure Resident #47 received diuretic medication as ordered. This affected seven residents (Resident #3, #22, #30, #50, #51, #63 and #68) of seven residents reviewed on the facility B hall for medication storage, and one resident (Resident #47) of five residents reviewed for medication. Findings include: 1. Resident #3 was admitted on [DATE] with diagnoses including heart failure, cerebral infarction and diabetes mellitus II with diabetic nephropathy. Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 required supervision for all activities of daily living (ADL) and his cognition was intact. Resident #3's May 2021 physician orders revealed an order for Percocet tablet 10-325 milligram (mg), a pain medication every four hours for pain.…

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

Based on record review and interview, the facility failed to implement a restorative nursing program after reviewing it as a systemic problem at the Quality Assurance and Assessment meeting. This affected six residents (#14, #37, #38, #47, #50 and #57) of six residents who were identified by the facility as needing a restorative nursing program. Findings included: Record review was conducted of the facility document titled Quality Assessment and Performance Improvement Team Documentation, dated 04/14/2021. The identified problem was the restorative program. The goal was to develop a functional restorative program. The root causes for the lack of a restorative program were listed as COVID 19, not utilizing a process to enter restorative orders and write a restorative program, staffing challenges and not having a steady Director of Nursing since 12/25/2020. Interview was conducted on 05/25/2021 at 12:36 P.M. with Therapy Manager (TM) #765 who revealed there were currently six residents who were referred for restorative nursing programs (RNP) between 01/10/2020 and 04/16/2021 but there…

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, observation, and interview the facility failed to ensure a family member visiting Resident #182 adhered to the proper use of personal protective equipment in a quarantine room for droplet isolation for potential COVID 19, and also failed to ensure clean hoyer pad straps were stored without the straps sitting on the floor. This affected one resident (Resident #182) of three residents reviewed for transmission based precautions and had the potential to affect all 15 of 15 residents (Resident #7, #13, #29, #32, #53, #55,#54,#61, #62, #63, #67, #180, #181, #182, and #184) who used hoyer pads. Findings included: 1. Record review was conducted for Resident #182 who was admitted to the facility on [DATE] with diagnoses including Alzheimer dementia and unspecified psychosis. The resident resided on the A unit which the facility identified as the isolation unit for newly admitted or readmitted residents. An observation and interview was conducted on 05/18/2021 at 11:48 A.M. of Resident #182…

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

Based on record review, observation and interviews, the facility failed to maintain a food processor, used to make pureed foods, in proper working order. This had the potential to affect all 10 residents (#8, #10, #19, #20, #27, #40, #53, #54, #62 and #184) on a pureed diet. Findings included: Record review was conducted of the facility dinner menu for 05/19/2021. The main entree selection for the pureed diets included BBQ pork. A review of the pureed BBQ pork recipe showed a portion size was a half cup and the final product should be smooth. An observation was conducted with Culinary Director (CD) #704, District Manager (DM) #794 and [NAME] #738 on 05/19/21 from 2:49 P.M. to 3:47 P.M. of [NAME] #738 demonstrating how she prepared pureed BBQ pork for the dinner meal. [NAME] #738 used a seven quart Robo Coup R602Y Series E food processor to puree a premeasured amount of pork pieces in BBQ sauce she identified as being 13 half-cup portions. She dumped the entire amount into the Robo Coup and began blending the pork at 2:51 P.M. When asked by the surveyor what consistency she wanted…

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, observation, and interview, the facility failed to update the plan of care for Resident #50 to establish an objective, measurable weight goal for a physician prescribed weight loss diet. This affected one (Resident #50) of seven residents reviewed for nutrition. Findings included: Record review was conducted for Resident #50 who was admitted to the facility on [DATE] with diagnoses including hemiplegia following a stroke, unspecified convulsions, neuromuscular dysfunction, panic disorder, major depression, anxiety disorder and oropharyngeal dysphagia. Review of Resident#50's Minimum Data Set assessment dated [DATE] revealed she had intact cognition and required extensive assistance of two staff for bed mobility and transfers, total dependence of one person for toileting, set up only and supervision for eating and extensive assistance of one staff for hygiene. Resident #50's medical record showed an active physician order dated 12/22/2020 for a weekly weight. Review of the weight records…

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 ensure a bladder program was implement to restore Resident #1 bladder function to his base line. This affected one (Resident #1) of two residents reviewed for decline in activities of daily living (ADL). Findings include: Resident #1 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease, benign prostatic hyperplasia without lower urinary tract symptoms, and dementia with behavior disturbance. Resident #1's quarterly comprehensive Minimum Data Set (MDS) assessment, dated 10/29/20, revealed the resident required minimal assistance with toileting. Resident #1's annual comprehensive MDS assessment, dated 05/27/21, indicated the resident was severely cognitively impaired, and required extensive assistance with toileting. Interview on 05/19/2021 at 8:12 A.M. with State Tested Nursing Assistant (STNA) #711 revealed the resident was incontinent of urine, and would urinate inappropriately on the floor.…

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 provide sufficient eating assistance to Resident #37. This affected one (Resident #37) of eight residents reviewed for activities of daily living. Findings include: Resident #37 was admitted on [DATE] with diagnoses including dementia with behaviors, visual function, psychotic disorder, depression, anxiety, anemia, incontinence, hypertension, and hyperlipidemia. Observation on 05/17/21 from 11:40 A.M. to 12:45 P.M. revealed Resident #37's meal was in a divided plate with a dinner roll in one of the smaller compartments, carrots and green peas in the other small compartment, and the main entrée of pork and mashed potatoes were in the large compartment. The resident ate everything on the right side of her plate and left everything on the left side uneaten. Resident #37 was scraping the bottom of the empty right side of the plate, totally ignoring the food on the left side as if it did not exist. She consumed 100% coffee which was also 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, interview, and record review, the facility failed to ensure Resident #43 smoked safely. This affected one (Resident #43) of three residents reviewed for accident hazards. Findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia, and chronic obstructive pulmonary disease. Review of Resident #43's signed smoking contract, revealed on 12/15/20 the resident's son signed the facility's smoking policy. The resident smoking policy and standard procedures dated 04/01/16 revealed a supervised smoker is a resident that is unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling cigarette ash and extinguishing smoking materials and requires staff supervision when smoking. Also, sharing, bartering, or selling smoking materials with others, including other residents is not permitted; non-compliance may result in a change to smoking status and/or discharged from the facility.…

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 ensure Resident #32 had bowls for all meals to assist with eating. This affected one resident (Resident #32) of seven residents reviewed for nutrition. Findings include: Resident #32 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's disease type 2 diabetes and dysphagia. Resident #32's quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required extensive assistance with eating, that he held food in his mouth/cheeks or residual food in his mouth after meals. Review of Resident #32's physician orders dated 03/04/2021 revealed Patient needs food in individual bowls for every meal. Observation on 05/17/2021 at 11:40 A.M. and 4:10 P.M. Resident #32 was observed eating his lunch and his dinner meals off of a plate. Interview on 05/17/2021 at 4:17 P.M. with Therapy #765, Therapy #780, and Therapy #787 confirmed Resident #32 should have bowls with all of his meals. 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.