Arbors At Sylvania

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, staff interview, and facility policy the facility failed to ensure timely care and treatment was provided to address incontinence. This affected two (#40 and #63) of five residents reviewed for bowel and bladder incontinence services. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #40 admitted to the facility on [DATE] with the diagnoses including metabolic encephalopathy, severe protein-calorie malnutrition, depressed mood, stage 2 pressure ulcer to sacral region and left buttock. dysphagia, and anemia. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #40 was assessed with moderately impaired cognition, range of motion impairments to the bilateral upper and lower extremities, dependency on staff for the completion of activities of daily living including bed mobility and incontience care as Resident #40 was always incontinent of bowel and bladder. Resident #40…

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, staff interview, and review of the facility policy, the facility failed to ensure oxygen was running at the prescribed rate. This affected one resident (#29) reviewed for oxygen therapy. The facility identified 15 residents required the use of oxygen therapy. The facility census was 73. Findings include: Review of the medical record for Resident #29 revealed an admission date of 12/09/22 with admitting diagnoses of heart failure and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 revealed he was cognitively intact and required the use of oxygen. Review of the care plan revised 02/25 for Resident #29 revealed he was care planned for impaired cardiovascular stated related to heart failure with an intervention for oxygen therapy as ordered. Review of the current physician orders for 04/25 revealed Resident #29 was ordered oxygen at two liters per minute continuously via nasal cannula. Observation on 04/14/25 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 observation, medical record review, staff interview, and facility policy, the facility failed to ensure alternative and non-pharmacologic interventions were implemented to address pain in accordance with physician orders. This affected one (#177) of two residents reviewed for pain control interventions. The facility census was 73. Findings include: Review of the medical record revealed Resident #177 admitted to the facility on [DATE] with diagnoses including cauda equina syndrome, spinal stenosis lumbar region, abnormal posture, chronic venous hypertension, chronic pain, chronic fatigue, allergy status to unspecified drugs, medications and biological substances, and lumbago with sciatica. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #177 was cognitively intact, was able to make needs known, had limited bilateral lower extremity range of motion, required substantial to maximal assistance with activities of daily living, received scheduled and as needed (PRN) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the facility policy, the facility failed to keep the privacy curtain clean in the residents room. This affected one resident (#5) of 24 reviewed for environment. The facility census was 73. Findings include: Review of the medical record for Resident #5 revealed an admission date of 04/12/21 and an admission diagnosis of dementia. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed he was cognitively impaired and was dependent for all care. Review of the care plan revised 02/25 for Resident #5 revealed he was care planned for behaviors related to dementia of taking his brief off in bed. Observation on 04/15/25 at 1:28 P.M. revealed Resident #5's privacy curtain had several brown stains that were unidentifiable along the bottom of the privacy curtain approximately one third up the privacy curtain and approximately two feet in length. Interview on 04/15/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #569 verified 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, staff interview, facility documentation review, and facility policy review, the facility failed to ensure an allegation of medication diversion was reported to the Administrator in a timely manner. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant,…

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, facility documentation, and facility policy, the facility failed to ensure an allegation of medication diversion was thoroughly investigated. This affected one (#71) of three sampled residents reviewed for misappropriation. The facility census was 66. Findings include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, type II diabetes mellitus, coronary artery disease, protein calorie malnutrition, mild dementia, heart failure, anemia, bipolar disorder, major depression, dysphagia, anxiety disorder, hypertension, and dysphonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was assessed with intact cognition, required substantial assistance to full dependence for completion of activities of daily living, received scheduled and as needed pain medication, and received antianxiety, antidepressant, opioid medications. Review of a 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure wound treatments were completed per physician order. This affected one (#24) of three residents reviewed for wounds. The facility census was 66. Findings Include: Review of the medical record revealed Resident #24 admitted to the facility on [DATE]. Diagnoses included hypertension, dementia, anemia, depression, dysphagia, and muscle weakness. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/16/24, revealed Resident #24 was cognitively intact. The resident required assistance from staff for activities of daily living. Review of an interdisciplinary team progress note dated 01/05/24 revealed the wound to the bridge of Resident #24's nose was an area that began as a small open area that the resident continually picked at. Review of Resident #24's physician orders revealed an order dated 08/28/23 through 03/05/24 to cleanse the bridge of the nose with saline, pat dry, and apply 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, staff interview, and facility policy review, the facility failed to provide proper bed mobility assistance to a dependent resident resulting in a avoidable fall. This affected one (#19) of three resident falls reviewed. Facility census was 66. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include multiple sclerosis, type II diabetes, pseudobulbar affect, major depressive disorder, mild cognitive impairment, osteoarthritis, dementia, hypertension, attention and concentration deficit, difficulty walking, and anxiety disorder. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 11/01/23, revealed she had a severe cognitive impairment. Resident #19 required partial/moderate assistance with rolling from left to right. Review of Resident #19 fall incident report and progress notes, dated 11/23/23, revealed State Tested Nursing Aide (STNA) #101 was assisting Resident #19 with moving in bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility corrective action documentation, and policy review, the facility failed to ensure a resident with an indwelling urinary catheter had orders for the placement and received associated care with maintenance of the drainage system. This affected one (#1) of three residents reviewed for indwelling urinary catheters. The census was 70. Finding include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, metabolic encephalopathy, acute lymphadenitis, autoimmune encephalitis, muscle weakness, depression, hypertension, dysphagia, anxiety disorder, and Alzheimer's disease. Review of a nursing admission assessment dated [DATE] revealed Resident #1 was dependent with toileting and elimination with assistance. There was no documentation an indwelling urinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure there was documented evidence contained in the medical record to include the placement and care of an indwelling urinary catheter. This affected one (#1) of three residents reviewed for indwelling urinary catheters. The census was 70. Finding include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, metabolic encephalopathy, acute lymphadenitis, autoimmune encephalitis, muscle weakness, depression, hypertension, dysphagia, anxiety disorder, and Alzheimer's disease. Review of a nursing admission assessment dated [DATE] revealed Resident #1 was dependent with toileting and elimination with assistance. There was no documentation an indwelling urinary catheter was in place. Review of a nursing admission evaluation completed on 06/08/23 revealed Resident #1 was documented with a Foley catheter (indwelling urinary catheter) in place. Review of a Minimum Data Set…

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

Based on observation, staff interview, and review of the facility recipe, the facility failed to ensure pureed foods were the correct texture. This affected four residents (#3, #4, #8, and #27) the facility identified on a pureed diet. The facility census was 62. Findings include: Observation of dining on 12/19/22 at 11:45 A.M. revealed residents in the dining room eating lunch. Further observation of the pureed chicken pot pie revealed concerns regarding appropriate texture due to the varied appearance of the texture. Tasting on 12/19/22 at 11:56 A.M. of the pureed chicken pot pie by the surveyor and the Dietary Account Manager #367 confirmed it was not fully pureed. The surveyor suggested the skins of corn were still intact while the Dietary Account Manager #367 suggested it was skins of beans that were still intact. Continued interview at that time confirmed the texture was inappropriate to be served as a pureed texture. Review of the recipe for Pot Pie Filling, Chicken revealed For Pureed: Measure desired number of servings into food processor. Blend until smooth.

Based on staff interview and record review, the facility failed to ensure a Level 2 Pre admission Screen and Resident Review (PASRR) was completed for one (Resident #10) resident of four reviewed for a Level 2 PASRR. The facility census was 62. Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/12/21 with diagnoses of transient ischemic attack, dementia with other behavioral disturbance, altered mental status, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #10 had impaired cognition and required extensive assistance of two people for bed mobility and toileting, extensive assistance of one person for hygiene, and total dependence on two people for transfers. Further review revealed he received an antipsychotic and an antidepressant. Antipsychotics were received on a routine basis only. Review of a letter from the Ohio Department of Medicaid titled Preadmission Screening and Resident Review Result, dated 07/11/22, revealed a referral had been made for a Level II evaluation. Review…

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, resident observation and staff interview, the facility failed to ensure residents that required assistance with oral care were provided adequate care and services. This affected one resident (#1) of four residents reviewed for activities of daily living. The facility identified 29 residents that required staff assistance with activities of daily living. The census was 62. Findings include: Review of Resident #1's medical record revealed an admission date of 08/30/19. Diagnoses included anoxic brain damage, anogenital herpes viral infection, anxiety disorder, pseudobulbar affect, contracture of the left and right hands, dysphagia, localized edema, and contracture of the left and right shoulders. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed with impaired cognition and did not speak. The activities of daily living (ADLs) Care Area Assessment (CAA) as part of the annual MDS assessment revealed Resident #1 required the totally dependence…

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, record review, and review of the facility policy, the facility failed to ensure fall interventions were implemented for one (Resident #49) of two residents reviewed for fall interventions. The facility census was 62. Findings include: Review of the medical record for Resident #49 revealed an admission date of 04/23/21 with diagnoses of history of falling, difficulty in walking, and unsteadiness on feet. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #49 had impaired cognition and required supervision of one person for bed mobility and hygiene, was independent with setup help for transfers and eating, required limited assistance of one person for dressing, extensive assistance of one person for toileting. Review of the Fall Risk Assessment completed 05/20/22 revealed Resident #49 had a score of 17.0 indicating fall interventions were required. Review of the physician order dated 05/25/22 revealed Resident #49…

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, record review, and review of the facility policy, the facility failed to ensure enteral nutrition (tube feeding) was provided per physician orders for one (Resident #6) of two residents reviewed for enteral nutrition. The facility census was 62. Findings include: Review of the medical record for Resident #6 revealed an admission date of 09/10/22 with diagnoses of unspecified intracranial injury with loss of consciousness of unspecified duration, acute kidney failure, history of urinary tract infections. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #6 was rarely/never understood and was totally dependent on staff for all activities of daily life. Review of a physician order dated 12/01/22 revealed Resident #6 received enteral nutrition at 100 milliliters (ml) per hour for 12 hours daily from 6:00 P.M. to 6:00 A.M. Review of Resident #6's weight history revealed a significant weight loss of 19.9% over six months from 157.4…

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, medical record review, and review of facility policy, the facility failed to ensure physician orders were in place for oxygen use. This affected one (#24) of two residents reviewed for oxygen administration. The facility census was 62. Findings include: Review of the medical record for Resident #24 revealed an admission date of 11/23/22 and a readmission date of 12/14/22 with medical diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and received oxygen. Review of the current physician orders revealed no orders for oxygen. Review of the current care plan revealed Resident #24 received oxygen via nasal cannula at 3 liters per minute. Observation on 12/19/22 at 10:44 A.M. revealed Resident #24 wearing a nasal cannula and receiving oxygen at 3 liters per minute. Interview at that time with Resident #24 confirmed she…

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

Based on observation, staff interview, medical record review, review of facility policies, and review of manufacturer instructions ,the facility failed to ensure medications were administered as ordered. This resulted in three medication errors of 25 total opportunities for a medication error rate of 12%. This affected three (#17, #30 and #60) of nine residents observed during medication administration. The census was 62. Findings include: 1. Review of Resident #17's record revealed an admission date of 11/23/21. Diagnoses included acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type II, vitamin D deficiency, gastroesophageal reflux, atrial flutter, cerebral infarction, osteoarthritis, and dementia. Review of a physician order dated 12/13/22 revealed Resident #17 was ordered Insulin Detemir, 100 units per milliliter, with 15 units ordered to be injected subcutaneously each morning. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:13 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #17 from the top…

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

Based on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure insulin was administered as ordered. This affected three (#17, #30 and #60) of nine residents observed during medication administration and three (#17, #30 and #60) of three residents reviewed for insulin usage. The facility census was 62. Findings include: 1. Review of Resident #17's record revealed an admission date of 11/23/21. Diagnoses included acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type II, vitamin D deficiency, gastroesophageal reflux, atrial flutter, cerebral infarction, osteoarthritis, and dementia. Review of a physician order dated 12/13/22 revealed Resident #17 was ordered Insulin Detemir, 100 units per milliliter, with 15 units ordered to be injected subcutaneously each morning. Observation of Registered Nurse (RN) #300 on 12/20/22 at 8:13 A.M. revealed RN #300 completed hand hygiene, removed the individual bag labeled for Resident #17 from the top drawer of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the facility policy, the facility failed to ensure smoking safety for one resident (#10) of one reviewed for smoking. The facility identified eight residents who smoked. The facility census was 62. Findings include: Review of the medical record for Resident #49 revealed an admission date of 04/23/21 with diagnoses of history of falling, difficulty in walking, and unsteadiness on feet. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #49 had impaired cognition and required supervision of one person for bed mobility and hygiene, was independent with setup help for transfers and eating, required limited assistance of one person for dressing, extensive assistance of one person for toileting. Review of the Nursing Quarterly/Significant Change Evaluation dated 12/01/22 revealed a Safe Smoking Evaluation was completed on Resident #49 and the evaluation concluded Resident #49 was safe to smoke unsupervised in designated smoking…

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

Based on observation, review of Resident Council meeting minutes, staff interview, resident interview, and a resident group interview, the facility failed to address resident concerns regarding call lights being turned off by staff and needs not being met. This affected thirteen residents (#2, #5, #12, #21, #22 #26, #31, #33, #34, #47, #50, #57, and #60) who attended Resident Council during the months of December 2019, January 2020, and February 2020 and one resident (#23) whose light was turned off twice without care. This had the potential to affect all 59 residents in the facility. Findings include: Review of Resident Council minutes from 12/20/19, 01/17/20, and 02/19/20 revealed residents had a concern of call lights being turned off and staff not coming back. Thirteen residents (#2, #5, #12, #21, #22 #26, #31, #33, #34, #47, #50, #57, and #60) were in attendance over the three months. Observation on 02/24/20 at 8:58 A.M. revealed Resident #23's call light was activated. State Tested Nurse Aide (STNA) #400 was observed to exit the resident's room and the call light was turned…

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

Based on observation, staff interview, review of a daily medication refrigerator temperature log, and review of manufacturers' storage recommendations, the facility failed to store medication requiring refrigeration at the proper temperature in accordance with manufacturer recommendations. This had the potential to affect seven residents (#10, #17, #33, #47, #48, #50, and #61) identified by the facility as having orders for medications being stored in the refrigerator. The census was 59. Findings include: Observation on 02/27/20 at 9:42 A.M., revealed the medication refrigerator located in the Subacute East Unit medication room had an internal temperature of 30 degrees Fahrenheit (F). Resident medication found to be stored in the refrigerator included six unopened Humalog insulin pens, three unopened Lantus insulin pens, 10 unopened Novolog insulin pens, two unopened Basaglar insulin pens, three unopened Levemier insulin pens, and an unopened vial of Novolog insulin. Review of February 2020 daily medication refrigerator temperatures located in the Subacute East Unit medication room…

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

Based on observation, medical record review, review of list of supervised smoking residents, staff interview, and review facility policy, the facility failed to ensure residents who required supervision with smoking were not in possession of cigarettes and lighters. This affected one (#23) of one residents reviewed for smoking at the facility. The census was 59. Findings include: Review of Resident #23's medical record revealed an admission date of 04/23/19. Diagnoses included encephalopathy, hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, antisocial personality disorder, major depressive disorder, schizoaffective disorder bipolar type, hypertension, hyperlipidemia, heart failure, and diabetes type 2. Review of the last Minimum Data Set (MDS) assessment, dated 01/02/20, revealed Resident #23 was cognitively intact. Review of the care plan revealed Resident #23 was a supervised smoker. Review of list of residents who smoke provided by the facility revealed Resident #23 was a supervised smoking resident. Interview on 02/24/20 at 10:08…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to obtain laboratory tests as ordered by the physician and at the appropriate times to monitor therapuetic drug levels for one (#48) of one resident reviewed for intravenous antibiotic therapy. The facility census was 59. Findings include; Review of the medical record revealed Resident #48 admitted to the facility on [DATE]. Diagnoses included type 1 diabetes mellitus, vascular dementia with behavioral disturbance, benign prostatic hyperplasia, epilepsy, major depression, peripheral vascular disease, hypertension, atrial fibrillation, osteomyelitis, acute kidney failure, and history of transient cerebral attack. Review of the physician orders dated 02/04/20 revealed an order for the antibiotic Vancomycin 1250 milligrams (mg) to be administered intravenously (IV) every day shift for osteomylitis with the pharmacy to dose. Review of the February 2020 Medication Administration Record (MAR) revealed a physician order…

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

Based on observation, medical record review, and staff interview, the facility failed to wear clean gloves during medication administration for one (#45) resident. This had the potential to affect all 59 residents in the facility. Findings include: Review of Resident #45's medical record revealed an admission date of 12/31/19. Diagnoses included dysthymic disorder, chronic diastolic heart failure, obstructive sleep apnea, type 2 diabetes mellitus without complications, hypertension, major depressive disorder, hyperlipidemia, chronic kidney disease, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment, dated 01/08/20, revealed the resident was cognitively intact. Observation on 02/24/20 at 11:20 A.M. revealed Licensed Practical Nurse (LPN) #402 entered Resident #45's room for medication administration, which included an injection. LPN #402 dropped one disposable glove on the resident's floor, picked up the glove off the floor, and put it on. LPN #402 then administered medication, including an injection. Interview on 02/24/20 at 11:22 A.M. with LPN #402…

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.