Altercare Thornville Inc.

Based on observations, interview, and facility policy, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all 49 of the residents residing in the facility. The facility identified all 49 residents in the facility as receiving iced beverages from the main kitchen ice machine. Findings include: On 11/12/24 at 8:52 A.M. an observation revealed that the inside of the ice machine in the main kitchen had a red slimy substance next to the prepared ice. On the inside of the ice machine, on the right top near the cooling mechanism, a white crusty build-up was observed. An interview with Dietary Director #163 on 11/12/24 at 8:52 A.M. confirmed the presence of the red slimy substance next to the prepared ice and the white crusty build-up on the right side of the ice machine, near the cooling mechanism. An interview with the Assistant Director of Dietary Services #305 on 11/12/24 at 10:27 A.M. revealed that the ice machine was deep cleaned by an outside company that serviced the machine. The Assistant Director of Dietary Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to provide a homelike environment and ensure resident equipment was clean and well maintained. This affected four (#3, #13, #37, and #42) of four residents reviewed for environment. The facility census was 49. Findings included: 1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, need for assistance with personal care, and intracranial injury without loss of consciousness. Observation on 11/12/24 at 8:39 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway and the wheelchair cushion was caked in food debris and the extended brakes had frayed, gray duct tape on them. Interview on 11/14/24 at 8:00 A.M. with Regional Nurse Consultant #302 confirmed Resident #3's wheelchair cushion was caked in food debris and the extended brakes had frayed, gray duct tape on them. Interview on 11/14/24 at 8:46 A.M. with Physical Therapy…

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, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was treated with with dignity during and after dining. This affected one (Resident #3) of one resident reviewed for dignity. The facility census was 49. Findings include: Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, need for assistance with personal care, and intracranial injury without loss of consciousness. Review of the care plan, dated 08/06/21, revealed Resident #3 was to receive supervision during meals or food activities, as needed, and given verbal cues for chewing or swallowing. Review of the Minimum Data Set (MDS) assessment, dated 10/02/24, revealed Resident #3's cognition remained intact and she had no behaviors. The resident required setup or clean-up assistance for eating, was dependent on staff for dressing, and required maximum assistance for personal hygiene. Observation on 11/12/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy, the facility failed to ensure that advanced directives were prominently placed in Resident #100's and Resident #149's medical records. This affected two (Resident #100 and Resident #149) of two residents reviewed for advanced directives. The facility census was 49. Findings include: 1. Record review revealed Resident #100 was admitted on [DATE] with diagnoses that included surgical aftercare of the digestive system, intestinal obstruction, anemia, depression, gastroesophageal reflux, and malignant neoplasm of the prostate. Review of Resident #100's electronic and physical medical records revealed that a code status was not prominently displayed in either chart. Interview with Registered Nurse (RN) Supervisor #162 on [DATE] at 3:52 P.M. confirmed there were no advanced directives prominently displayed in Resident #100's medical chart. RN Supervisor #162 was unable to identify the code status of Resident #100. RN Supervisor #162 stated that advanced…

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, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was provided with adaptive equipment for meals per physician orders. This affected one (Resident #3) of one resident reviewed for adaptive equipment. The facility census was 49. Findings include: Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, the need for assistance with personal care, and intracranial injury without loss of consciousness. Review of the care plan, dated 08/06/21, revealed Resident #3 should receive supervision during meals or food activities, as needed, and given verbal cues for chewing or swallowing. The care plan dated 07/28/21 revealed the resident was at risk for altered nutrition related to tremors, dysphagia, and the need for adaptive equipment to facilitate self feeding with interventions that included to apply a left handed weighted glove and a left handed curved spork supplied…

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, interviews, review of facility policy, and review of equipment manuals, the facility failed to ensure alternating air mattresses were functional and set on the correct settings for pressure ulcer/injury prevention. This affected two (Resident #12 and Resident #13) of six residents reviewed for skin interventions. The facility census was 49. Findings include: 1. Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, dysphagia, dementia, and chronic obstructive pulmonary disease. Resident #12's record revealed the resident did not have any pressure ulcers. The record further revealed Resident #12 was 114.5 pounds on 06/07/23. Resident #12 was receiving hospice services and did not have additional weights in the record. Review of the Minimum Data Set (MDS) assessment, dated 08/31/24, revealed Resident #12 had a pressure reduction device on her bed. Review of the care plan, dated 01/19/23, 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.

Based on review of medical records, observation, and staff interview the facility failed to ensure fall interventions were in place for Resident #8 per the plan of care. This affected one resident (Resident #8) of two residents reviewed for falls. The facility census was 49. Findings include: Review of Resident #8's medical record revealed an admission date of 05/23/23 and diagnoses including senile degeneration of the brain, dementia, depression, and a history of traumatic brain injury. Review of the physician orders for Resident #8 revealed on 11/09/23, the resident was ordered non-skid strips to the floor in front of the resident's toilet. Review of Resident #8's the care plan, dated 06/05/24, revealed the resident was at risk for falls/injury related to history of falls, incontinence, altered mental status, and impaired gait. Interventions included non-slip strips to the floor in front of the toilet. Observation of Resident #8's bathroom on 11/13/24 at 2:28 P.M. revealed non-skid strips were not present in front of the residents toilet. Interview on 11/13/24 at 2:50 P.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to store respiratory equipment in a sanitary manner. This affected one (Resident #42) of one resident reviewed for respiratory equipment. The facility census was 49. Findings included: Record review revealed Resident #42 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and hypertension. Review of physician orders revealed an order, dated 04/28/24, for Ipratropium-Albuterol solution for nebulization 0.5 milligrams to 3 milligrams for inhalation due to wheezing, cough and congestion every six hours as needed. Observation on 11/12/24 at 10:57 A.M. revealed Resident #42's nebulizer was placed on her floor, plugged into the wall. The nebulizer was covered in small, brown spots. Interview on 11/12/24 at 8:55 A.M. with Lead Receptionist #146 confirmed the nebulizer was covered in small, brown spots and placed on the floor while plugged in. Receptionist #146 stated the nebulizer should not have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the self-reported incident (SRI) and the facility's investigation, review of the facility policy, record review, and staff interviews, the facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Administrator or designee. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the Alleged Perpetrator's assignment on 10/06/23. The facility census was 40. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included senile degeneration of brain, displace fracture of right femur, acute respiratory failure with hypoxia, depression, acute kidney failure, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severe cognitive impairment. Review of the SRI control number 239906 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 review of the self-reported incident (SRI) and investigation, review of the facility's policy, record review, and staff interviews, the facility failed to protect the other residents from potential abuse by not immediately removing State Tested Nursing Assistant (STNA) #150 from the facility after there was an allegation of verbal abuse to Resident #27. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the STNA #150's assignment on 10/06/23. The facility census was 40. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included senile degeneration of brain, displace fracture of right femur, acute respiratory failure with hypoxia, depression, acute kidney failure, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had…

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 one resident (#9) was treated in a dignified manner. This affected one of one reviewed for dignity. The facility census was 44. Findings Included: Review of the medical record for Resident #9 revealed an initial admission date of 11/16/20 with the latest readmission of 08/23/21 with the diagnoses including hypertension, major depressive disorder, anxiety disorder, sleep apnea, chronic obstructive pulmonary disorder, osteoarthritis, obesity, fibromyalgia, full incontinence of feces, weakness, dysphagia, retention of urine, hyperlipidemia, atrial fibrillation, congestive heart failure, dyskinesia of esophagus, diverticulum of esophagus, diverticulosis of intestine, dysphagia, hypothyroidism, cerebral infarct, schizophrenia, dementia and gastro-esophageal reflux disease. Review of the plan of care dated 11/16/20 revealed the resident was incontinent of bladder and was at risk for altered dignity, skin breakdown and urinary tract infection (UTI). Interventions included administer medication per physician orders, assess…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, and facility policy review, the facility failed to ensure a resident's (Resident #18) call light was kept within reach. The deficient practice affected one resident (Resident #18) of one reviewed for call lights. The facility census was 44. Findings Include: Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, generalized muscle weakness, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), including bed mobility, transfers, dressing, and toileting. Resident #18 had…

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 clarify conflicting code statuses for one resident (#20). This affected one of five residents reviewed for advance directives. The facility census was 44. Findings Include: Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar disorder, contracture of left hand and contracture of left wrist. Review of the Do Not Resuscitate (DNR) Comfort Care form dated 07/13/21 revealed the resident elected to have the code status DNR…

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, staff interview, and facility policy review, the facility failed to notify one resident's (Resident #146) physicians when STAT (immediate) labs were not completed as ordered. The deficient practice affected one (Resident #146) of one reviewed for notification. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. Review of the physician orders for August 2023 revealed Resident #146 had the following orders: STAT WBC (white blood cell) dated 08/03/23 and STAT CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) dated 08/05/23. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a Facility Reported Incident (FRI) investigation, staff interview, and facility policy review, the facility failed to report an allegation of physical abuse to the Ohio Department of Health (ODH) within two hours for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for abuse. The facility census was 44. Findings Include: Review of the medical record for Resident #35 revealed an admission date on 12/09/21. Medical diagnoses included encephalopathy, cognitive communication deficit, Alzheimer's Disease, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had severely impaired cognition. Resident #35 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of the progress note dated 01/16/23 at 8:37 P.M. revealed Registered Nurse (RN) #130 entered Resident #35's room to administer medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility failed to submit a new Pre-admission Screening/Resident Review (PASRR) once a resident received a new diagnosis of major depressive disorder. This affected one (Resident #37) of two residents reviewed for PASRR. The census was 44. Findings included: 1. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, sepsis, hypertension, sleep apnea, atrial fibrillation, heart failure, aortic aneurysm of unspecified site, kidney failure, and gastroesophageal reflux disease. Review of chart revealed Resident #37 was given a new diagnosis of major depressive disorder on 03/02/23. Review of Pre-admission Screening/Resident Review (PASRR) dated 03/07/22 revealed no evidence of Resident #37 having a mood disorder. Interview on 08/09/23 at 12:01 P.M. with Social Services Director #171 confirmed a new PASRR had not been completed to indicate Resident #37 had a new diagnosis of major depressive disorder. A policy 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, interview, and policy review, the facility failed to ensure showers were completed for Resident #37 and failed to ensure toenail care was completed for Resident #18. This affected two (Resident #18 and #37) of two residents reviewed for activities of daily living (ADL). The facility census was 44. Findings included: 1. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, sepsis, hypertension, sleep apnea, atrial fibrillation, heart failure, aortic aneurysm of unspecified site, kidney failure, and gastroesophageal reflux disease. Review of a minimum data set (MDS) completed on 05/06/23 revealed Resident #37 has a brief interview for mental status (BIMS) of 15 indicating he is cognitively intact, he requires an extensive assist of two people for bed mobility, extensive assist of one person for toileting, and total dependence of one person for bathing. Review of a shower schedule revealed Resident #37 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident #18) had a soft cervical collar placed when out of bed as ordered. Additionally, the facility failed to timely complete initial comprehensive wound assessments for one resident's (Resident #146) surgical wounds. The deficient practices affected two residents (Residents #18 and #146) of two residents reviewed for quality of care. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to timely complete initial comprehensive assessments of identified pressure injury areas for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of three residents reviewed for pressure ulcers. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities 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, observations, resident and staff interviews, and facility policy review, the facility failed to complete timely incontinence care and toileting assistance for two residents (Residents #9 and #18). The deficient practice affected two residents (Residents #9 and #18) of two reviewed for bowel and bladder. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including toileting. Resident #18 had functional limitations in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#34) received timely meal assistance. The facility also failed to ensure one resident's (#18) fluids were accessible. Additionally the facility failed to provided one resident (#9) the physician ordered two handled cup with meals. This affected one ( Resident #34) of one resident reviewed for nutrition, one ( Resident #18) of one resident received for hydration and one ( Resident #9) of 13 sampled residents. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #34 revealed an initial admission date of 05/20/21 with the diagnoses including contracture of muscle, multiple sites, dementia, malignant neoplasm of female breast, diabetes mellitus, hyperlipidemia, vitamin D deficiency, anxiety disorder, trigeminal neuralgia, aortic valve stenosis, aortic valve insufficiency, peripheral vascular disease, depression, osteoporosis, hypertension, hematuria and abnormal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to address pharmacy recommendations within thirty days and did not follow up on recommended labs. This affected three (Resident #9, #10, and #28) of three residents reviewed for medication regiment reviews. The facility census was 44. Findings included: 1. Record review revealed Resident #9 admitted to the facility on [DATE] with diagnoses including left femur fracture, hypertension, major depressive disorder, chronic obstructive pulmonary disease, hypokalemia, anxiety disorder, sleep apnea, atrial fibrillation, diastolic congestive heart failure, schizophrenia, unspecified dementia, and hypothyroidism. Review of minimum data set (MDS) from 05/20/23 revealed Resident #9 was cognitively intact and had no behaviors. Review of care plan from 11/16/20 revealed Resident #9 takes psychotropic medications including an antidepressant, antianxiety, and antipsychotic. Review of orders revealed Resident #9 was prescribed buspirone (an antianxiety medication) 10…

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 facility to ensure medications were properly stored and labeled. This affected Resident #20 using the Lantus insulin pen and had the potential to affect 27 residents (#1, #2, #4, #5, #7, #9, #10, #11, #13, #14, #17, #19, #20, #21, #22, #25, #26, #27, #29, #30, #34, #36, #37, #38, #40, #76 and #94) who reside on the 100 unit. The facility census was 44. Findings Include: 1. On 08/10/23 at 3:05 P.M., observation of the 100 unit medication cart revealed one Lantus insulin pen laying in the drawer with no name or date on the insulin pen. The Lantus insulin pen had been pulled from the emergency drug kit (EDK). Further observation revealed a Lispro Insulin pen laying in the drawer with no name or date on the insulin pen. The Lispro insulin pen was also pulled from the EDK. Interview with Licensed Practical Nurse (LPN) #127 at the time of the observation revealed she was unsure what resident the insulin pens were pulled from the EDK. She removed six empty clear plastic bags from the insulin drawer on the medication cart and revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of lab results, staff interview, and review of the facility laboratory agreement, the facility failed to obtain STAT (immediate) labs as ordered for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of one reviewed for laboratory testing. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, Type II Diabetes Mellitus with foot ulcer, and chronic kidney disease stage 3b. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices in the manner to prevent the potential spread of infection in the area of pressure ulcer dressing change and catheter care. This affected one resident (#20) of two residents reviewed for pressure ulcers and one resident (#37) of one resident reviewed for catheter. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar…

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.