Ayden Healthcare Of Toledo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to store medications in a safe and sanitary manner and failed to ensure medications were not able to be used after expiration dates. This had the ability to affect all 67 residents residing in the facility. The facility census was 67. Findings Included: 1. Observation of the South hall medication refrigerator on [DATE] at 8:59 A.M. with Licensed Practical Nurse (LPN) #250 revealed the refrigerator contained a brown liquid substance on the bottom shelf. Located on that shelf, soaked in brown liquid, was an expired vial of influenza vaccine. The expiration dated was [DATE]. Interview with LPN #250 on [DATE] at 9:04 A.M. verified the refrigerator contained a brown liquid substance and contained expired influenza vaccine. 2. Inspection of the North medication storage refrigerator on [DATE] at 9:19 A.M. with LPN #226 revealed a bottle of the neurotransmitter epinephrine was found with an expiration date of [DATE]. Interview with LPN #226 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.

Based on observation, staff interview, and policy review, the facility failed to ensure the refrigerators at the nurses stations for resident food was kept clean and food labeled and dated. This has the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings include: 1. Observation on 07/15/24 at 8:20 A.M. of the refrigerator in the North nurse's station revealed seven sandwiches in plastic wrap not dated and one baggy of lettuce, tomato, meat, and onion that appeared to be watered down with soggy and was not dated. There was also one carton of oat milk that was not labeled or dated. Interview on 07/15/24 at 8:23 A.M. with Unit Manager (UM) #109 verified the seven sandwiches were not dated and the baggy with lettuce, tomato, meat, and onions was not dated. UM #109 stated the food in the resident refrigerators should be dated. 2. Observation of the refrigerator in the South nurse's station on 07/15/24 at approximately 8:30 A.M. revealed six sandwiches wrapped in plastic wrap, one bowl of chili, and two take out bags containing Chinese food…

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 resident interview, staff interview, review of Resident Council minutes, review of call light audits, and policy review, the facility failed to thoroughly address Resident Council concerns in a timely manner. This had the potential to affect 18 (#1, #8, #9, #11, #12, #17, #22, #24, #29, #33, #35, #41, #44, #45, #49, #52, #53, and #65) residents who regularly attended Resident Council meetings. The facility census was 67. Findings include: Review of Resident Council minutes dated 09/29/23 revealed nursing concerns regarding food sitting too long on the food cart. Review of Resident Council minutes dated 11/27/23 revealed nursing concerns regarding, on the weekends, first shift food carts are passed slower. Review of Resident Council minutes dated 12/27/23 revealed nursing concerns regarding call light response times were slow on all shifts and weekends, and food/meal pass took too long at times. Review of Resident Council minutes dated 01/25/24 revealed nursing concerns regarding call lights, medication administration, meal carts, staffing, noise levels, and smoking times.…

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 medical record review, resident interview, staff interview, and policy review, the facility failed to conduct care conferences as required. This affected eight (#9, #14, #17, #30, #34, #57, #59, and #62) of 26 residents reviewed for care conferences. The facility census was 67. Findings Included: 1. Review of Resident #9's medical record revealed an admission date of 09/28/23. Diagnoses included infection/inflammatory reaction due to internal left hip prosthesis, chronic obstructive pulmonary disease, peripheral vascular disease, alcoholic cardiomyopathy, chronic kidney disease, alcoholic hepatitis, alcohol abuse, and femur fracture. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a high cognitive function. Review of Resident #9's most recent care plan revealed the resident was at risk for alteration in activity participation related to a significant health change. The resident tired easy and her pain level may hinder participating in activities she enjoyed…

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, resident interview, staff interview, and policy review the facility failed to ensure the facility maintained safe smoking practices as care planned and per the facility smoking policy. This directly affected four (#33, #59, #64, and #328) of four residents reviewed for smoking with the potential to affect all 15 (#1, #6, #7, #27, #28, #29, #33, #34, #41, #45, #46, #47, #59, #64, and #328) residents who smoke. Additionally, the facility failed to ensure fall interventions were in place as care planned. This affected one (#14) of three residents reviewed for falls. The facility census was 67. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 02/02/24 with diagnoses including cerebral infarction, acute kidney failure, hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side, type two diabetes, gastrointestinal hemorrhage, major depressive disorder, chronic viral hepatitis C, hypertension,…

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 maintain a safe and homelike environment. This had the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings Included: 1. Observation on 07/10/24 at 2:28 P.M. revealed water was running out of the fire dampers from the ceiling onto the floor in the South halls of the facility. Buckets and wet floor signs were in place on four of the areas, but three additional areas had water sitting on the floor. Interview with Maintenance Assistant (MA) #162 on 07/10/24 at 2:30 P.M. revealed the rain water was coming down the vents from the duct work. MA #162 also confirmed the fire dampers contained a black substance on them. Interview with Maintenance Supervisor (MS) #163 on 07/10/24 at 3:03 P.M. revealed the water was coming in through the fire dampers from the roof. MS #163 stated she had been caulking them, but it was not containing the issue. MS #163 also stated it was not connected to 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 review of the medical record, review of hospital documentation, resident and staff interview, and review of email correspondence, the facility failed to ensure meal accommodations were made to honor religious fasting preferences. This affected one (#21) of one resident reviewed for religious preferences. The facility census was 67. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/06/23 with diagnoses of choric obstructive pulmonary disease, type II diabetes mellitus, and nutritional deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition and required setup and clean-up assistance for eating. Review of Resident #21's weight history revealed weights were obtained on 03/05/24, 04/04/24, 04/26/24, 05/02/24, and 06/03/24. No significant weight loss occurred between 03/05/24 and 06/03/24. Review of a nutrition progress note dated 04/16/24 revealed Dietetic Technician (ST) #261 recommended weekly weights…

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 completed Minimum Data Set (MDS) assessments were completed and transmitted within required timeframes. This affected two (#43 and #61) of two residents reviewed for MDS assessment submission. The facility census was 67. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 02/07/24 and discharge date of 02/27/24. Diagnoses included human immunodeficiency virus (HIV), malignant neoplasm of the rectum and anal canal, rectal polyp, Alzheimer's disease, Parkinson's disease, and neoplasm of the colon. Review of Resident #43's MDS assessments revealed no MDS was completed for a death in the facility on 02/27/24. Further review of the resident's MDS assessments revealed the last completed MDS assessment was on 02/14/24 for admission. 2. Review of the medical record for Resident #61 revealed an admission date of 01/16/24 and discharge date of 01/25/24. Diagnoses included acute kidney failure,…

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 Minimum Data Set (MDS) assessments accurately reflected the resident's status. This affected one (#33) of 26 residents reviewed for MDS assessments. The facility census was 67. Findings include: Review of the medical record for Resident #33 revealed an admission date of 05/16/24 with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. Review of the admission nursing observation dated 05/18/24 revealed Resident #33 received oxygen therapy at three liters per minute via nasal cannula. Review of the provider progress note dated 05/20/24 revealed Resident #33 required oxygen via nasal cannula and was receiving oxygen at the time of the provider's visit. Review of the comprehensive admission MDS assessment dated [DATE] revealed Resident #33 had intact cognition and indicated Resident #33 was not on oxygen therapy. Review of a physician order dated 07/08/24 revealed Resident #33 received oxygen via nasal…

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 policy review the facility failed to implement a care plan to address the resident's desire to smoke. This affected one (#64) of four residents reviewed for smoking. The facility census was 67. Findings include: Review of the medical record for Resident #64 revealed a most recent re-admission date of 05/25/24 with diagnoses including intestinal obstruction, anterior dislocation of the right humerus, retroperitoneal hematoma, fracture of the right fibula, fracture of the shaft of the right tibia, hypertension, cognitive communication deficit, and post-traumatic stress disorder. Review of an admission smoking assessment dated [DATE] revealed Resident #64 was a current smoker and assessed as safe to smoke with supervision. Further review of the smoking assessment revealed a notation the smoking plan of care was updated. Review of Resident #64's care plan dated 04/16/24 revealed no smoking care plan as of 07/09/24. Interview on 07/09/24 at 10:15 A.M. with Director…

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 consulted wound care specialist orders were completed. This affected one (#175) of three residents reviewed for wounds. The facility census was 67. Findings include: Review of the medical record for Resident #175 revealed an admission date of 04/26/24 and a discharge date to home on [DATE]. Diagnoses included type II diabetes mellitus and cutaneous abscess of the left foot. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #175 had intact cognition and displayed no rejection of care. Resident #175 required substantial /maximal assistance for toileting. Further review revealed Resident #175 had an infection of a diabetic foot ulcer, a surgical wound, and moisture associated skin damage. Review of a consultant wound care physician progress note dated 04/30/24 revealed an initial assessment was completed on Resident #175 and identified she had irritant dermatitis from body fluid to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure residents had timely access to vision services. This affected one (#17) of two residents reviewed for vision services. The facility census was 67. Findings include: Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included other sequelae of cerebral infarction, chronic combined systolic and diastolic heart failure, chronic obstructive pulmonary disease, diabetes mellitus, major depressive disorder recurrent, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact and had corrective lenses. Interview on 07/09/24 at 7:59 A.M. with Resident #17 revealed his glasses had been broke for at least a month or two and indicated the glasses needed a screw replaced. Resident #17 stated he was unable to wear his glasses in the current condition. Observation on 07/09/24 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 observation, staff interview, medical record review, review of a mattress manual, and review of the facility policy, the facility failed to ensure pressure wound treatments were completed as ordered and wound care interventions were in place and functioning appropriately. This affected two (#16 and #56) of three residents reviewed for wounds and pressure reducing interventions. The facility census was 67. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 01/28/21 with diagnoses of bullous pemphigoid and type II diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and a stage four pressure ulcer (Full-thickness skin and tissue loss). Review of Resident #16's current care plan revealed he had a pressure ulcer to the left heel due to immobility. Interventions included to administer treatments as ordered. Additionally, Resident #16 had potential/actual impairment to skin…

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, resident interview, and policy review the facility failed to ensure residents received timely and adequate assistance with incontinence care. This affected one (#62) of two residents reviewed for incontience. The facility census was 67. Findings Included: Review of Resident #62's medical record revealed an admission date of 01/25/24. Diagnoses included osteomyelitis the right femur, liver cancer, lung cancer, malnutrition, tachycardia, absence of the right leg below the knee, bone cancer, and a pressure ulcer on admission. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function and required substantial/maximal assistance for toileting and rolling. Review of Resident #62's most recent care plan revealed he was at risk for impaired skin integrity related to weakness, difficulty ambulating, current wounds, cancer which metastasized, incontinence, cognitive deficits, pain, and depression. Interview…

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 medical record, hospital document review, and staff interview, the facility failed to ensure physician orders and dietitian recommendations were implemented to address weight changes. This affected one (#21) of two residents reviewed for nutrition. The facility census was 67. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/06/23 with diagnoses of choric obstructive pulmonary disease, type II diabetes mellitus, and nutritional deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition and required setup and clean-up assistance for eating. Review of Resident #21's weight history revealed weights were obtained on 03/05/24, 04/04/24, 04/26/24, 05/02/24, and 06/03/24. No significant weight loss or trend occurred between 03/05/24 and 06/03/24. Review of a nutrition progress note dated 04/16/24 revealed Dietetic Technician (DT) #261 recommended weekly weights for four weeks and a nutritional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure physician orders for oxygen administration were in place prior to administering oxygen to residents. This affected two (#26 and #33) of two residents reviewed for oxygen administration. The facility census was 67. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 04/06/23 with diagnoses of chronic respiratory failure with hypoxia and asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Review of the medical record for Resident #26 revealed she discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the physician orders on 07/08/24 at 1:30 P.M. revealed no current order for oxygen via nasal cannula. Further review revealed a physician order dated 06/09/23 and discontinued on 03/17/24 for continuous three liters of oxygen via nasal cannula.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered with a physician's order and were available for administration. This affected two (#55 and #175) of six residents reviewed for medications. The census was 67. Findings include: 1. Review of Resident #55's medical record revealed an admission date of 05/05/23. Diagnoses included human immunodeficiency virus (HIV) and bacteremia. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident did not receive as needed pain medication. Review of Resident #55's care plan revealed the resident was at risk for alteration in comfort and was to be administered medications as ordered. Review of Resident #55's nursing progress note dated 02/04/24 revealed the resident complained of leg pain which was rated a seven on a 10-point pain scale with 10 indicating the highest pain level. 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 medical record review, staff interview, and facility policy the facility failed to ensure pharmacy recommendations were timely reviewed and implemented. This affected two (#14 and #17) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, atherosclerotic heart disease of native coronary artery, heart failure, major depressive disorder, acquired absence of the right leg above the knee, chronic atrial fibrillation, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of Resident #14's pharmacy medication regimen review dated 10/22/23 revealed an order clarification request for the anticoagulant Eliquis tablet 2.5 milligram (mg) with instructions to give one tablet by mouth one time a day for atrial fibrillation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure physician orders for gradual dose reductions of psychotropic medications implemented in a timely manner. This affected one (#17) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included other sequelae of cerebral infarction, chronic combined systolic and diastolic heart failure, chronic obstructive pulmonary disease, diabetes mellitus, major depressive disorder recurrent, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. Review of Resident #17's medication regimen review dated 06/13/23 revealed a gradual dose reduction for the antipsychotic risperidone tablet 0.5 milligram (mg) with instructions to give one tablet by mouth in the morning for schizoaffective and an order for risperidone one (1) mg tablet give…

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 consulted wound care specialist laboratory orders were completed. This affected one (#175) of three residents reviewed for wounds. The facility census was 67. Findings include: Review of the medical record for Resident #175 revealed an admission date of 04/26/24 and a discharge date to home on [DATE]. Diagnoses included type II diabetes mellitus and cutaneous abscess of the left foot. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #175 had intact cognition and displayed no rejection of care. Resident #175 required substantial /maximal assistance for toileting. Further review revealed Resident #175 had an infection of a diabetic foot ulcer, a surgical wound, and moisture associated skin damage. Review of a consultant wound care physician progress note dated 05/07/24 revealed orders for laboratory testing, complete blood count, basic metabolic panel, c-reactive protein, and…

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

Based on medical record review, resident interview, staff interview, and review of a facility policy, the facility failed to keep accurate medical records. This affected one (#56) of 26 resident's medical records reviewed. The facility census was 67. Findings include: Review of Resident #56's medical record revealed an order dated 06/03/24 for the resident to obtain a Velcro wrist brace/splint to the left wrist/hand for comfort. Interview with Resident #56 on 07/08/24 at 9:56 A.M. revealed she was ordered a brace/splint for her left hand due to arthritis, but it was uncomfortable so she refused to wear the brace. Observation revealed the brace was in a drawer in the bedside table. Interview with Licensed Practical Nurse (LPN) #215 on 07/09/24 at 2:08 P.M. revealed Resident #56 had her splint in place to the left hand. The resident had a gauze bandage on her right hand from surgery. LPN #215 stated she was confused with the surgery bandage and splint, and LPN #215 stated she had been signing off that the splint was in place when it was not including on 07/09/24. 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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure antibiotic stewardship was practiced when treating residents with urinary tract infections (UTIs). This affected three (#12, #18, and #50) of three residents reviewed for UTIs. The facility census was 67. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 02/02/21 with diagnoses of type II diabetes mellitus and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition, was frequently incontinent of bladder, and required partial/moderate assistance for toileting hygiene. Review of the June 2024 medication administration record (MAR) revealed Resident #12 received cephalexin (antibiotic) capsule 500 milligrams (mg) with instructions to give one capsule by mouth three times a day for infection, presumed UTI for seven days until finished. Further review revealed Resident #12 received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of immunization records, staff interview, review of policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered pneumococcal and influenza vaccinations per CDC recommendations. This affected two (#14 and #30) of five residents reviewed for influenza and pneumococcal vaccinations. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included type two diabetes mellitus and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Interview on 07/15/24 at approximately 9:00 A.M. with the Director of Nursing (DON) revealed the facility could provide no documentation to verify Resident #14 was offered the pneumococcal vaccine. 2. Review of the medical record revealed Resident #30 was admitted on [DATE]. Diagnoses included schizophrenia and depression. 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, review of immunization records, staff interview, review of a policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure COVID-19 vaccinations were offered per CDC recommendations. This affected two (#14 and #30) of five residents reviewed for COVID-19 vaccinations. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included type two diabetes mellitus and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #14 was cognitively intact. Review of the immunization record revealed Resident #14 last received the COVID-19 vaccine on 08/11/22. Interview on 07/11/24 at 3:42 P.M. with the Director of Nursing (DON) revealed there was no further documented refusals or attempts to provide Resident #14 the COVID-19 vaccination booster. 2. Review of the medical record revealed Resident #30 was admitted on [DATE].…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure monitoring of a medication included obtaining blood sugar levels as ordered by the physician. This affected one (#2) of three residents reviewed for administration of medications and associated monitoring. The facility census was 75. Findings include: Review of Resident #2's medical record revealed an admission date of 03/13/21,with the diagnoses including: type 2 diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, schizoaffective disorder, anemia, adjustment disorder with mixed anxiety and depressed mood, hypertension, psychoactive substance abuse and non-pressure chronic ulcer of back. Review of the most current minimum data set assessment, dated 02/01/24, assessed Resident #2 with intact cognition, required supervision/touch assistance with activities of daily living, occasionally incontinent of urine and continent of bowel, received antipsychotic, antidepressant and opioid medications. Review of a nursing plan of care implemented on 03/21/21 to address 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 observation, medical record review, staff interview, policy review, and manufacturer instructions for use review, the facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in delay in administration of insulin, and antidepressant medication. This affected one (#1) of three residents observed during medication administration. The facility census was 75. Findings include: Observation on 06/05/24 at 9:45 A.M., noted Licensed Practical Nurse ( LPN) #300 obtain a blood glucose monitor from the medication cart and proceed into Resident #1 room. Upon entry Resident #1 had concluded the breakfast meal consuming between 50-75% of the meal. LPN #300 obtained a blood sample from Resident #1 left index finger which resulted at a blood sugar level of 286. LPN #300 returned back to the medication cart and obtained a Insulin Lispro pen, placed a needle to the pen and returned to the room. At 10:00 A.M., LPN #300 dialed six (6) units to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure a dependent received bathing and associated grooming. This affected one (#3) of three sampled residents reviewed for the provision of activities of daily living in a facility census of 73. Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included myocardial infarction, coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, anxiety disorder, and chronic kidney disease stage 3. Review of the Minimum Data Set assessment dated [DATE] documented Resident #3 was assessed with moderate cognitive impairment, no occurrence regarding refusal of care, required substantial to maximal assistance for the completion of activities of daily living. Review of the 02/19/24 nursing plan of care addressed Resident #3 at risk for activity of daily living (ADL) self-care performance deficit related to (r/t) weakness, difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure incontinence care was provided timely to a dependent resident. This affected one (#3) of three sampled residents reviewed for the provision of urinary incontinence care in a facility census of 73. Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included myocardial infarction, coronary artery disease, hypertension, chronic obstructive pulmonary disease, obesity, anxiety disorder, and chronic kidney disease stage 3. Review of the Minimum Data Set assessment dated [DATE] documented Resident #3 was assessed with moderate cognitive impairment, no occurrence regarding refusal of care, required substantial to maximal assistance for the completion of activities of daily living including bed mobility and was incontinent of bowel and bladder. Review of the 02/19/24 nursing plan of care addressed Resident #3 had bladder incontinence…

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 residents received ordered medications upon admission. This affected two residents (#15 and #71) of three residents reviewed for admission medications. The facility census was 70. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/28/23 and discharge date of 01/19/24 with diagnoses including but not limited to metabolic encephalopathy, altered mental status, acute respiratory failure with hypoxia, fluid overload, congestive heart failure, type two diabetes, unspecified convulsions, chronic kidney disease stage three, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of five which indicated Resident #71 had severely impaired cognition. Resident #71 required extensive assistance for Activities of Daily Living (ADLs). Review of physician orders dated 12/28/23 revealed divalproex…

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, and staff interview, the facility failed to provide incontinence care. This affected two (Residents #4 and #5) of three sampled residents reviewed for incontinence care. The facility census was 70. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including, a non-pressure chronic ulcer on the buttock and a history of urinary tract infection. Review of the bowel and bladder assessment, dated 02/15/23, documented Resident #4 was to void appropriately without incontinence but less than daily and incontinent of stool one to three times weekly. Resident #4 was assessed as immobile or required two person assistance with toileting, never aware of need to toilet. Review of the Minimum Data Set (MDS) assessment, dated 10/23/23, revealed Resident #4 was cognitively intact. The resident required maximum/substantial staff assistance with activities of daily living including toileting and bed mobility and was frequently incontinent of bowel and…

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, staff interview, and review of the facility's policy, the facility failed to ensure a clean and sanitary kitchen and utilized the appropriate hand hygiene when serving food. This had the potential to affect all residents, except Resident #55 and Resident #59, who the facility identified as not receiving food by mouth. The facility census was 56. Findings include: 1. Observation on 08/29/22 at 9:00 A.M. of the kitchen revealed a thick, heavy buildup of dirt, bugs, and an unidentifiable sawdust like substance on top of the dishwasher and on the windowsill next to the dishwasher. Interview on 08/29/22 at 9:08 A.M. with Dietary Supervisor #452 verified the buildup of debris on top of the dishwasher and windowsill next to the dishwasher. Observation on 08/31/22 at 11:00 A.M. of the kitchen revealed a thick layer of dust and grime on the kitchen exhaust hood, piping along the wall, and on the windowsill. Interview on 08/31/22 at 11:16 A.M. with Corporate Dietary Manager #498 verified the buildup of dust and grime stating they had cleaned some of it…

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 observation, medical record review, staff interview, review of the facility's policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore Personal Protective Equipment (PPE) as required. This affected Residents #109, #110, and #111 and had the potential to affect all 56 residents residing in the facility. Findings include: Review of Resident #109's medical record revealed Resident #109 was admitted to the facility on [DATE] with no known COVID-19 vaccination status. On 08/26/22, the physician ordered for Resident #109 to be placed in New admission COVID-19 Quarantine; May discontinue after seven days with a negative test on day five-to-seven of quarantine. Review of Resident #110's medical record revealed the resident was admitted to the facility on [DATE] with no known COVID-19 vaccination status. On 08/26/22, the physician ordered for Resident #110 to be placed in New admission COVID-19 Quarantine; May discontinue after seven days with a…

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 staff and resident interviews, observations, review of the facility's policy, and record review, the facility failed to ensure the resident's concerns regarding activities were addressed timely after the issue was identified during resident council meetings. This affected the four residents who attended the resident council meetings regularly, Residents #11, #39, #47, and #51). The facility census was 56. Findings include: Review of the Resident Council Meeting Minutes revealed there were meeting held monthly from January 2022 to June 2022. There were no minutes found by the facility for July 2022 or August 2022. Resident #11, #38, #47 and #51 attended resident council meetings regularly. On 06/29/22, it was noted the residents expressed concerns regarding lack of activities such as going outside and bingo. There was no evidence there was any follow up to the resident's concerns regarding activities. Interview during the Resident Council Review on 08/30/22 at 10:59 A.M. with the Resident Council President, Resident #47, revealed the facility had no scheduled activities…

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 interview, observations, staff interviews, and review of the facility's policy, the facility failed to ensure activity programs were designed, scheduled, and implemented to meet the interests and needs of the residents. This affected four (Residents #6, #7, #10, and #159) of four residents reviewed for activities. The facility census was 56. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 10/29/20. Diagnoses included hemiplegia, epilepsy, major depressive disorder, and stroke. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately cognitively impaired. Resident #6 was totally dependent on staff for transfer. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 08/29/22 revealed support and interventions for his preference to stay in his room daily and relax in 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 observation, medical record review, and staff interview, the facility failed to ensure residents were provided with wheelchairs that were appropriately fitting. This affected one (Resident #44) of 24 residents observed for assistive devices. The facility census was 56. Findings include: Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included epilepsy and morbid obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was identified as alert with intact cognition and required extensive physical assistance from one staff for bed mobility and transfers. Resident #44 weighed 370 pounds, utilized a walker and wheelchair for mobility, and was at risk for pressure ulcer development with no current skin breakdown. Review of the care plan dated 08/01/22 revealed Resident #44 was at risk for for pressure ulcers due to weakness, difficulty ambulating, obesity, diabetes mellitus type II, and congestive heart failure.…

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 interview, observation, staff interview and review of the facility's policy, the facility failed to ensure residents were transferred out of bed and provided showers as requested by the resident. This affected one (Resident #6) of four residents reviewed for choices. The facility census was 56. Findings include: Review of Resident #6's medical record revealed an admission date of 10/29/20. Diagnoses included hemiplegia, epilepsy, major depressive disorder, and stroke. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately cognitively impaired. Resident #6 was totally dependent on staff for transfer. Resident #6 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 08/29/22 revealed support and interventions for self-care…

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, medical record review, and staff interview, the facility failed to ensure a resident's wheelchair armrest were maintained and intact. This affected one (Resident #11) of 24 residents reviewed for medical equipment. The facility census was 56. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] Resident #11 was assessed with intact cognition and required supervision with staff assistance with ambulation. Review of the nursing plan of care dated 01/17/22 revealed the care plan addressed Resident #11's activity in daily living (ADL) self care deficit related to schizophrenia (delusional psychotic paranoia), bipolar disorder, anxiety, depression, dementia, and generalized weakness. Interventions included uses assistive/adaptive equipment including as wheelchair, hemi-walker and cane. Observations on 08/29/22 at 9:48 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and review of the facility's skin management program policy, the facility failed to ensure pressure relief devices were placed in use for a resident identified with a pressure ulcer to the hip. This affected one (Resident #55) of two residents reviewed for pressure ulcer relief interventions. The facility identified five current residents with pressure ulcers. The facility census was 56. Findings include: Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, adult failure to thrive, alcohol abuse, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and was dependent on staff for the completion of activities of daily living. Resident #55 was incontinent of bowel and bladder, received nutrition via tube feeding, was at risk for pressure ulcer development with one…

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, and review of the facility's medication administration policy, the facility failed to ensure the residents received medications as physician ordered resulting in a medication error rate above five percent (%). There were four medications errors out of 36 opportunities, resulting in a medication rate of 11.11%. This affected two (#32 and #111) of three residents reviewed for medication administration. The facility census was 56. Findings include: 1. Observations on 08/30/22 at 8:00 A.M. revealed Licensed Practical Nurse (LPN) #496 obtained the glucose monitor and proceeded to Resident #32's room. Resident #32 had concluded eating his breakfast meal. LPN #496 proceeded to obtain a blood sugar reading which resulted in error and at 8:02 A.M. obtained a second blood sugar reading of 235. LPN #496 returned to the medication cart and obtained the residents medications including lispro insulin four international units (IU) via syringe, proair hydrofluoroalkane (HFA) aerosol inhaler, and fluticasone furoate-vilanterol aerosol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident interview, and staff interview, the facility failed to ensure residents were provided adaptive devices to support independence during meals. This affected one (Resident #6) of six residents reviewed for meals and dining. The facility identified there were no residents who required adaptive equipment to assist at meal time. The facility census was 56. Findings include: Review of Resident #6's medical record revealed an admission date of 10/29/20. Diagnoses included hemiplegia, epilepsy, major depressive disorder, and stroke. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately cognitively impaired. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 08/29/22 revealed support and interventions for potential for altered nutrition and hydration. Interventions included a sipper (two handled lidded) cup and…

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 staff interview, review of personnel records, review of Staff Vaccination COVID-19 log and infection control log, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, the facility failed to ensure staff were fully COVID-19 vaccinated, had an approved exemption, or had been identified as appropriate for a temporary delay per Center for Disease Control and Prevention (CDC) guidance. The vaccination rate for the facility was calculated at 98.0%. The facility census was 56. Finding included: Review of the Staff Vaccination COVID-19 log, provided 08/29/22, revealed the facility had 99 employees with 69 employees vaccinated and 30 employees with a religious exemption. The Staff Vaccination COVID-19 log indicated 100% of staff were vaccinated or had an approved religious exemption. However, State Tested Nursing Assistant (STNA) #432 and #466 did not have completed religious exemption forms available during the survey. This revealed 28 employees with a religious exemption indicating a 98% of staff were…

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

Based on record review, staff interview, and review of facility policy, the facility failed to issue appropriate notifications of the ending of skilled Medicare Part A services. This affected one resident (48B) of three reviewed for liability notices. The facility identified six residents with Medicare as their primary payer source and discharged from skilled services in the last six months. The total facility census was 47. Findings Include: Review of Resident #48B's Beneficiary Protection Notification Review revealed Medicare Part A skilled services started on 07/09/19 and last day of covered services was 08/16/19. An Advanced Beneficiary Notice of Non-coverage form was provided and signed 08/13/19. Resident #48B chose Option 3 I don't want the therapies listed above. I understand with this choice I am not responsible for payment and cannot appeal to see if Medicare would pay. No Notice of Medicare Non-Coverage (NOMNC) was found. Interview on 09/19/19 at 12:37 P.M. with the Administrator verified the NOMNC form was not provided to Resident #48B and the wrong notification had 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 medical record review, staff interview and policy review, the facility failed to provide a written notice of transfer/discharge for one (Resident #25) of three residents reviewed for hospitalization. The facility census was 47. Findings include: Review of the medical record for Resident #25 revealed an admission date of 11/21/18. Diagnoses included malignant neoplasm of unspecified site of right breast, anemia, constipation, lymphedema, major depressive disorder, single episode, dementia in other diseases classified elsewhere without behavioral disturbance, hyperlipidemia, unspecified injury at unspecified level of cervical spinal cord, and essential hypertension. Review of the residents medical record revealed the resident was discharged to the hospital on [DATE] for pitting edema to the right arm, the resident was readmitted on [DATE]. On 06/10/19, the resident was at a lymphedema clinic, was admitted to the hospital from there for bleeding from right arm and readmitted to the facility on [DATE].…

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 provide bed-hold policy information to residents at the time of hospital transfer. This affected three (Resident #48A, Resident #13 and Resident #25) of three reviewed for hospitalization. The facility census was 47. Findings include: 1. Review of Resident #48A's medical record revealed an admission date of 05/15/19 and a discharge date of 06/28/19. Diagnoses included chronic respiratory failure, insomnia, acute embolism and thrombosis of deep vein of right lower extremity, type II diabetes, sleep apnea, anemia, major depressive disorder, hyperlipidemia, pain, fibromyalgia, COPD, anxiety disorder, obesity, heart failure, and gout. Review of Resident #48A's Minimum Data Set (MDS) assessment revealed an Entry MDS was completed 05/15/19 and a Discharge Return Not Anticipated MDS was completed 06/21/19. Review of Resident #48A's progress notes revealed Resident #48A was transferred to the hospital on [DATE]. 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 observation, medical record review, staff interview and review of facility policy, the facility failed to assess residents for risk of unsafe wandering and continued use of wander guard ankle bracelet alarms as an intervention. This affected one (Resident #18) of one reviewed for wandering and elopement. The facility identified three residents with wander guards in place. The facility census was 47. Findings Include: Review of Resident #18's medical record revealed an admission date of 12/18/15. Diagnoses included heart disease, hypokalemia, dementia, major depressive disorder, hyperlipidemia, hypothyroidism, hypertension, calculus of kidney, and anxiety disorder. Review of Resident #18's physician's order revealed an order dated 05/24/18 for an alert bracelet to the left ankle and to check placement every shift. Check function on night shift for the diagnosis of dementia. Review of Resident #18's Minimum Data Set (MDS) assessments dated 08/07/18, 11/01/18, and 01/29/19, indicated the resident used a…

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, and staff interview, the facility failed to ensure ongoing individualized activities were provided. This affected one (Resident #34) of twelve residents reviewed for activity involvement in a facility census of 47. Findings include; Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, dementia, dysphagia, chronic kidney disease, low back pain, muscle weakness, major depression, osteoarthritis, and history of venous thrombosis and embolism. Review of the most current minimum data set assessment (MDS) assessment dated [DATE] revealed Resident #34 had adequate hearing, ability to understand/understood, visual impairment without the use of corrective lenses, severely impaired cognition, no behavioral symptoms including refusal of care, and total dependence on staff for the completion of activities of daily living. Review of the residents plan of care dated 05/25/18 revealed plan of care was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide care and services as ordered and care planned for constipation. This affected one (Resident #25) of five resident's reviewed for unnecessary medications. The facility census was 47. Findings include: Review of the medical record for Resident #25 revealed an admission date of 11/21/18. Diagnoses included malignant neoplasm of unspecified site of right breast, anemia, constipation, lymphedema, major depressive disorder, single episode, dementia in other diseases classified elsewhere without behavioral disturbance, hyperlipidemia, unspecified injury at unspecified level of cervical spinal cord, and essential hypertension. Review of the care plan dated 08/19/19 revealed Resident #25 was on pain medication therapy related to breast cancer, surgical wounds, and lymphedema. Resident #25 was at risk for communication and cognitive deficits in the areas of receptive and expressive language impacting resident's ability to effectively…

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, resident interview, staff interview and review of facility policy, the facility failed to ensure residents' smoking materials were kept secured. This affected two residents, (Resident #9 and #199) of two reviewed for smoking. The facility identified nine residents who smoked. The facility census was 47. Findings Include: 1. Review of Resident #199's medical record revealed an admission date of 09/04/19. Diagnosis included type II diabetes, bipolar disorder, major depressive disorder, hypertension, tachycardia, heart disease, hyperlipidemia, fibromyalgia, lupus, and anxiety. Review of Resident #199's smoking assessment dated [DATE] revealed Resident #199 smoked ten or more times per days. Resident #199 was able to light her own cigarettes. Resident #199 needed the facility to store the lighter and cigarettes and had a plan of care in use to assure the resident was safe while smoking. Review of Resident #199's Minimum Data Set (MDS) dated [DATE] revealed a Brief…

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 dietary menu spreadsheet, the facility failed to ensure residents were provided with adequate nutrition and therapeutic diets. This affected one (Resident #28) of three residents reviewed for nutrition in a facility census of 47. Findings include: Resident #28 admitted to the facility on [DATE] with the diagnoses including, congestive heart failure, dysphagia, depression, acute respiratory failure, history of pulmonary edema, gastrointestinal hemorrhage, anemia, type II diabetes mellitus with neuropathy, end stage renal disease receiving hemodialysis, atrial fibrillation, metabolic encephalopathy, coronary artery disease, arteriovenous fistula, and fibromyalgia. On 02/04/19, a plan of care was implemented to address the residents need for dialysis related to renal failure, hyperlipidemia, proteinuria and adenoma. Interventions included daily weights, diagnostic test as ordered, and attends dialysis on Monday, Wednesday, and Friday. On 03/29/19, a…

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

Based on observation, medical record review, staff interview, and facility medication administration via enteral tube policy review, the facility failed to ensure medications administered via Gastrostomy tube (G-tube) were provided in accordance with facility policy which resulted in a medication error rate of greater than five percent (5%). A total of 28 opportunities were observed with six medication errors for a medication error rate of 21.43 %. This affected one (Resident #13) of four residents reviewed for medication administration. The facility census was 47. Findings include: Review of the medical record for Resident #13 noted the following physician orders; 05/07/19, lexapro 10 milligrams (mg) daily via G-tube, 06/21/19, norvasc 5 mg daily via-G-tube, aspirin 81 mg chewable via G-tube, eliquis 2.5 mg twice daily via G-tube, lisinopril 10 mg once daily via G-tube, and lopressor (metoprolol) 25 mg twice daily via G-tube. On 09/02/19, give 20 milliequivalents (meq) per(/) 15 milliliters (ml) liquid potassium daily via G-tube. No physician order for crushing or cocktailing…

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.