Concord Care Center Of Toledo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interviews, and review of facility policy, the facility failed to ensure residents received services and equipment to adequately maintain vision. This affected two (Resident #09 and Resident #62) of two residents reviewed for vision. The facility census was 78. 1. Review of the medical record for Resident #62 revealed an admission date of 07/02/20. Diagnoses included glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. Interview on 07/28/25 at 9:35 A.M. with Resident #62 revealed he had two pairs of glasses that were both broken. Concurrent observation revealed one pair of silver glasses had a missing temple arm on the left side and were ill-fitting due to being bent at the right temple arm. A second pair of black glasses was missing the left lens. Interview on 07/31/25 at 12:25 P.M. with the Director of Nursing confirmed there was no documentation available to confirm Resident #62 had seen an eye doctor. Continued 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 record review, observation, staff interview, and policy review, the facility failed to administer oxygen per physician orders. This affected one resident (#37) of one resident reviewed for oxygen administration. The facility census was 78. Review of Resident #37's medical record revealed an admission date of 10/08/24. Diagnoses included chronic obstructive pulmonary disease, anemia in chronic kidney disease, and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Resident #37's physician's orders revealed an order for oxygen at two to three liters per minute via nasal canula as needed for shortness of breath. Observation on 07/28/25 at 11:25 A.M. of Resident #37's oxygen concentrator revealed her oxygen to be running at four liters per minute via nasal cannula. Observation on 07/28/25 at 3:17 P.M. of Resident #37's oxygen concentrator revealed her oxygen to be running at four liters per minute via…

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

Based on medical record review, staff interview, and review of facility policy the facility failed to obtain laboratory testing as ordered. This affected one (Resident #62) of one resident reviewed for laboratory testing. The facility census was 78. Review of the medical record for Resident #62 revealed an admission date of 07/02/20. Diagnoses included glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. Continued review of this medical record revealed provider orders dated 05/08/25 for laboratory testing in January and June.Interview on 07/31/25 at 12:00 P.M. with [NAME] President of Clinical Services #301 confirmed Resident #62 had provider orders for laboratory testing to be completed in June and the testing had not been processed.Review of facility policy dated November 2018 titled Lab and Diagnostic Test Results - Clinical Protocol revealed staff would arrange for ordered laboratory testing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure residents had access to dental services. This affected one (#09) of two residents reviewed for dental services. The facility census was 78.Review of the medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, muscle weakness, unspecified psychosis, essential hypertension, type two diabetes mellitus without complications, and muscle wasting and atrophy.Review of the Minimum Data Set (MDS) assessment, dated 06/23/25, revealed the resident was cognitively intact. Review of care plan, revised on 03/22/21, revealed Resident #09 has some/all missing natural teeth due to poor dental hygiene. The Resident wears upper and lower dentures. Interventions included to coordinate arrangements for dental care, transportation as needed and as ordered.Interview on 07/28/25 at 10:55 A.M. with Resident #09 revealed all of 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.

Based on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to accurately document in the medical record. This affected one (Resident #03) of one resident reviewed for accuracy of documentation. The facility census was 78. Review of the medical record for Resident #03 revealed an admission date of 06/03/25, diagnoses included hemiplegia and hemiparesis affecting the left side following cerebral infarction (stroke), depression, anxiety, heart disease, and bone density disorders.Further review of the medical record for Resident #03 revealed progress notes dated 06/03/25, 06/04/25, 06/06/25, 06/08/25, and 06/27/25 indicating Resident #03 participated in physical therapy. Review of provider orders for Resident #03 revealed there were no orders for physical therapy on admission, nor had physical therapy orders been initiated since admission.Interview on 07/28/25 at 10:00 A.M. with Resident #03 revealed she was not receiving physical therapy services.Interview on 07/30/25 at 10:35 A.M. with Physical Therapist #300 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, review of the admission packet and review of facility policy the facility failed to offer influenza vaccines as required. This affected one (#13) of five residents reviewed for influenza vaccinations. The facility census was 78.Review of the medical record revealed Resident #13 was admitted on [DATE] with re-entry on 11/25/24. Diagnoses included schizoaffective disorder depressive type, delusional disorders, mood disorder due to known physiological condition, chronic kidney disease stage 3, auditory hallucinations, essential hypertension, type two diabetes mellitus without complications, schizophrenia, chronic obstructive pulmonary disease, and unspecified systolic heart failure.Review of the Minimum Data Set (MDS) assessment, dated 06/04/25, revealed the resident was cognitively intact. The influenza vaccine was documented as offered and declined. Review of immunization documentation, dated 10/14/24, revealed the influenza vaccine was marked…

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

Based on record review and staff interview, the facility failed to ensure a physician was notiifed of a resident not receiving antipsychotic medications as ordered by the physician. This affected two (#36 and #53) of four residents reviewed for notification. The facility census was 79. Findings include: 1. Review of Resident #36's medical revealed an admission date of 12/09/19, with diagnoses of schizophrenia, obesity, pseudobulbar affect (PBA), vitamin D deficiency, asthma, bipolar disorder, difficulty in walking, hypokalemia, constipation, and weakness. Review of Resident #36's orders revealed Clozapine (an antipsychotic medication) 100 milligrams (mg) was ordered by the physician to be administered two times a day (BID) by mouth (PO) beginning 01/15/19. Review Resident #36's electronic medication administration record (eMAR) for November 2024 revealed Resident #36 did not receive her physician-ordered dose of Clozapine 100 mg in the evening on 11/08/24, 11/09/24, or 11/10/24. Review of a progress note dated 11/15/24 at 4:24 P.M., which revealed the physician and guardian 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of policies, review of hospital records, and staff interviews, the facility failed to ensure the mental health of a resident was met when antipsychotic medications were not administered per physician orders. This affected two (#36 and #53) of four residents reviewed for behavioral services. The facility census was 79. Findings include: 1. Review of Resident #36's medical revealed an admission date of 12/09/19, with diagnoses of schizophrenia, obesity, pseudobulbar affect (PBA), vitamin D deficiency, asthma, bipolar disorder, difficulty in walking, hypokalemia, constipation, and weakness. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 10/29/24, revealed a Brief Interview of Mental Status (BIMS) Score of 15, indicating Resident #36 was cognitively intact. Review of the most recent care plan for revealed Resident #36 used psychotropic medications related to schizophrenia. The goal was for the resident to remain free of psychotropic-related drug…

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 m medical records review, review of pharmacy records, and staff interviews, the facility failed to ensure that physician-ordered medications were available and administered per physcian orders. This affected two residents (#36 and #53) of four residents reviewed for pharmaceutical services. The facility census was 79. Findings include: 1. Review of Resident #36's medical revealed an admission date of 12/09/19, with diagnoses of schizophrenia, obesity, pseudobulbar affect (PBA), vitamin D deficiency, asthma, bipolar disorder, difficulty in walking, hypokalemia, constipation, and weakness. Review of Resident #36's orders revealed Clozapine (an antipsychotic medication) 100 milligrams (mg) was ordered by the physician to be administered two times a day (BID) by mouth (PO) beginning 01/15/19. Review of the Pharmacy Manifest of Delivery, dated 10/21/24, revealed Resident #36 had 60 tablets (30-day supply) of Clozapine 100 mg delivered. Review Resident #36's electronic medication administration record (eMAR)…

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 policy review, the facility failed to administer medications as ordered to ensure a medication error rate of not greater than five (5) percent (%). A total of three medication errors were observed out of 37 opportunities for a medication error rate of 8.11%. This affected one (#60) of three residents reviewed for medication administration. The census was 78. Findings include: Review of the medical record for Resident #60 revealed the resident was admitted on [DATE] and had diagnoses that included major depressive disorder and alcohol-induced dementia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #60, dated [DATE], revealed the resident had intact cognition. Review of physician orders dated [DATE] revealed Resident #60 was ordered dorzolamide hydrochloride two (2) % solution with instructions to instill one drop in both eyes two times daily for glaucoma and was ordered a multivitamin one tablet once daily for…

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

Based on review of facility education documentation, review of facility assessment, review of employee files, review of self-reported incidents (SRI), and staff interview, the facility failed to provide adequate behavioral health training to care for residents with mental and psychosocial disorders. This had the potential to affect all residents residing in the facility. The facility census was 80. Findings include: Review of the facility assessment, revised 11/25/24, revealed the facility competency staff on caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post traumatic stress disorder (PTSD), and implementing nonpharmacological interventions. Review of the facility provided education documentation, the facility provided one in-service in the previous 12 months, on 07/10/24, for employees that covered de-escalation tips. This training did not meet the criteria in the regulation as it did not assess staff competency on caring for residents with mental and psychosocial disorders, as well as residents with a history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, self-reported incident (SRI) review, witness statement review, employee file review, and policy review, the facility failed to ensure a resident was free physical and verbal abuse from staff. This affected one (#39) of eleven residents reviewed for abuse,with the potential to affect 49 of residents on Unit 1 and 3. The facility census was 80. Findings include: Review of the facility electronic medical record revealed Resident #39 was admitted on [DATE], with diagnoses of: malignant neuroleptic syndrome, anxiety, chronic pain syndrome, urinary incontinence, unspecified lack of coordination, schizophrenia, difficulty in walking, pseudobulbar affect (PBA), delusional disorders, hypertension (HTN), bipolar disorder, psychological and behavioral factors associated with disorders or diseases classified elsewhere, altered mental status, major depressive disorder, other impulse disorder, borderline personality disorder, cognitive communication deficit, unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self-reported incident review, staff interview, and review of policy, the facility failed to timely report an alleged verbal abuse. This affected one (#39) of eleven residents reviewed for abuse, with a potential to affect 32 residents residing on Unit 1. The facility census was 80. Findings include: Review of the facility electronic medical record revealed Resident #39 was admitted on [DATE], with diagnoses of: malignant neuroleptic syndrome, anxiety, chronic pain syndrome, urinary incontinence, unspecified lack of coordination, schizophrenia, difficulty in walking, pseudobulbar affect (PBA), delusional disorders, hypertension (HTN), bipolar disorder, psychological and behavioral factors associated with disorders or diseases classified elsewhere, altered mental status, major depressive disorder, other impulse disorder, borderline personality disorder, cognitive communication deficit, unspecified intellectual disabilities, antisocial personality disorder, chromosomal abnormality,…

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, policy review, and staff interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff. This had the potential to affect 30 (#7, #12, #13, #15, #17, #22, #24, #27, #29, #33, #34, #35, #40, #46, #47, #49, #50, #53, #54, #57, #62, #66, #67, #69, #70, #72, #74, #75, #78, and #79) residents, who reside on the first floor. The facility census was 80. Findings include: An environmental tour was conducted with Certified Nursing Assistant (CNA) #139 between 9:31 A.M. and 10:06 A.M. The following was verified at the time of observation by CNA #139: • room [ROOM NUMBER] contained a blanket hanging in the window in place of a curtain. • The first-floor resident shower room had black mold like substance growing on the wall by the shower, a broken radiator cover, and there was a foul odor throughout the first-floor resident shower room. • The first-floor dining room contained peeling paint on multiple walls throughout, a blanket hanging in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, pest control report review, policy review, and staff interview, the facility failed to ensure the first floor was free from gnats and ants. This had the potential to affect 30 (#7, #12, #13, #15, #17, #22, #24, #27, #29, #33, #34, #35, #40, #46, #47, #49, #50, #53, #54, #57, #62, #66, #67, #69, #70, #72, #74, #75, #78, and #79) residents, who reside on the first floor. The facility census was 80. Findings include: Observations conducted during the facility tour of the first floor on 11/19/24 beginning at 9:31 A.M., revealed approximately 15-20 gnats flying throughout the first-floor resident area located in the hallway, kitchen, and resident rooms. Observation on 11/19/24 at 9:39 A.M., revealed ants in the resident restroom shared by residents in rooms [ROOM NUMBERS]. Observation on 11/19/24 at 9:45 A.M., revealed ants the resident restroom shared by residents in rooms [ROOM NUMBERS]. Interview on 11/19/24 at 9:45 A.M., with Certified Nursing Assistant (CNA) #139 verified these findings.…

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 policy, the facility failed to ensure the smoking area was maintained in a clean and safe manner. This had this potential to affect 40 (#2, #3, #4, #5, #6, #9, #11, #13, #15, #17, #18, #19, #21, #25, #26, #30, #36, #37, #38, #40, #41, #42, #44, #47, #48, #49, #54, #57, #58, #60, #61, #63, #64, #72, #73, #76, #78, #79, #80, and #81) who smoke. The facility census was 80. Findings include: Observation during the tour of the facility on 11/19/24 at 8:59 A.M., revealed four restaurant-style flammable booths constructed of a wooden frame, cloth and vinyl covering, and foam for cushion in the smokers area, one booth by the metal waste can, was being utilized for disposing of cigarettes with approximately 75 cigarette butts under it; two metal ash trays lined with aluminum foil; a cigarette butt in the seat of one restaurant-style booth located against the exterior wall of the building; a trash can with cigarette butts and trash contained inside located next to the exterior wall of the facility; cigarette butts under the edge 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, review of housekeeping check list, review of facility assessment, and review of policy, the facility failed to maintain a clean and safe environment. This directly affected eight (#16, #54, #55, #56, #63, #64, #65, and #90) residents with the potential to affect all 77 residents in the facility. The census was 77. Findings include: Observation on 10/28/24 at 7:05 A.M., upon entering the facility revealed the ceiling light with missing a cover, brown stained and bowing ceiling tiles, carpeting pulled away from the wall, dark brown streaks and various odd, shaped areas of black discoloration on the tan colored bench and the two blue and white chairs, brown colored carpeting with dark colored staining and worn, thinning paths in front of the facility locked entry door, and spider webs and dust hanging from the ceiling where the wall and ceiling join. Additional observations during the facility tour on 10/28/24 from 9:00 A.M. until 11:30 A.M. revealed: • The ceiling vent in 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.

Based on observation, staff interview and review of policy, the facility failed to ensure smoking safety was maintained. This affected seven (#18, #31, #32, #33, #34, #37 and #38) of seven residents observed for smoking safety. The facility census was 77. Findings include: Observation on 10/28/24 at 9:00 A.M., revealed State Tested Nursing Assistant (STNA) #135 opened an exterior door of the building and entered the fenced courtyard off Station 1 hallway. Seven residents (#18, #31, #32, #33, #34, #37 and #38) went out the door. STNA #135 then closed the exterior door, handed each resident a cigarette, and lighted each cigarette. At 9:03 A.M., STNA #135 opened the exterior door, returned inside the building and closed the exterior door. STNA #135 stood inside the door in the hallway talking with other staff and residents. At 9:10 A.M., STNA #135 opened the exterior door and in a single file, each of the seven residents, (#18, #31, #32, #33, #34, #37 and #38) came back into the building. Continuous observation on 10/28/24 from 9:00 A.M. until 9:10 A.M., revealed Residents #18, #31,…

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 of medication administration, staff interview, record review, and review of a policy for administering medications, the facility failed to ensure a medication error rate of less than five percent. 27 opportunities were observed with two medication errors, resulting in a 7.41 percent error rate. This affected one (Resident #15) of three residents observed for medication administration. The facility census was 76. Findings include: Review of Resident #15's medical record revealed a physician order dated 08/24/22 for guaifenesin (antihistamine) 600 milligram (mg) tablets, two tablets (1,200 mg) every 12 hours by mouth for allergies. There was also a physician order dated 07/16/22 for fluticasone propionate suspension 50 micrograms (mcg) per actuation, one spray in each nostril two times per day for rhinitis (allergies). Observation on 05/29/24 at 8:50 A.M. revealed Licensed Practical Nurse (LPN) #30 administered the 17 medications to Resident #15, in the form of oral, topical, and inhaled medications. Among these medications, LPN #30 administered two guaifenesin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure funds were conveyed timely upon death for one resident (#100); and failed to notify five residents (#2, #4, #30, #51, and #71) when their personal funds account balance was within two hundred dollars of the state allowed limit. This affected six (#2, #4, #30, #51, #71, and #100) of ten residents reviewed for funds conveyance and notices. The facility census was 80. Findings Include: 1. Review of the medical record for Resident #100 revealed Resident #100 expired in the facility on [DATE]. Review of the resident account list dated [DATE] revealed Resident #100 had ninety-three dollars and thirty-six cents in the personal funds account. Interview on [DATE] at 2:00 P.M. with Business Office Manager #300 verified Resident #100 had current funds in the account and the funds should have been conveyed within 30 days to social security. 2. Review of the medical record for Resident #2 revealed an admission date of [DATE]. Review of the quarterly…

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, record review, and review of the facility policy, the facility failed to obtain written authorizations by the resident or resident representative to open a Resident Trust account. This affected three (#3, #37 and #74) of ten residents reviewed for Resident Trust accounts. The facility census was 80. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 07/16/21. Review of the quarterly statement documentation, Resident #3 had an established trust account with transactions dating between 01/01/24 and 03/31/24. The current balance was $0.34. No written authorization was provided stating Resident #3 authorized the facility to manage a resident trust account. Interview on 04/24/24 at 2:00 P.M. with Business Office Manager (BOM) #300 confirmed no written authorizations were available showing Resident #3 authorized the facility to manage a resident trust account. 2. Review of the medical record for Resident #37 revealed an admission date of 05/03/18. Review of the quarterly statement documentation, Resident #37 had an…

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 medications were administered to the residents without any significant medication errors. This affected one (#77) of five residents observed for medication administration. The facility census was 80. Finding include: Review of the medical record for Resident #77 revealed an admission date of 03/24/23, Diagnoses included type II diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment and received insulin injections daily. Review of the physician order dated 04/13/24 Resident #77 was to receive insulin Lispro (100 units per milliliter (u/ml) subcutaneously per sliding scale before meals and at bedtime. Observation of medication administration on 04/24/24 at 8:56 A.M. of Licensed Practical Nurse (LPN) #306 for Resident #77 revealed LPN #306 removed a vial of Novolog insulin from the top drawer of the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, observations, and review of the facility policy, the facility failed to ensure medications were stored, labeled, and kept secure at all times. This affected five (#34, #44, #63, and two residents who were not identified) of five residents reviewed for medication storage. The facility census was 80. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 02/12/19. Diagnoses included schizoaffective disorder and bipolar disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively intact. Interview on 04/24/24 at 9:40 A.M. with Resident #44 verified he has entered the medication storage room number two and removed an orange medication box from the medication room for Licensed Practical Nurse (LPN) #301. Resident #44 stated he did this upon LPN #301's request due to the orange medication box being too heavy for LPN #301 to move. Interview on 04/24/24 at 10:00 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.

Based on medical record review, staff interview and review of facility policy, the facility failed to notify the physician of unavailable treatment supplies for ordered wound care. This affected one (#8) of three residents reviewed for wound care. The facility census was 80. Findings include: Review of the medical record for Resident #8 revealed an admission date of 06/09/23 with diagnoses including non-pressure chronic ulcer of left lower leg. Review of the plan of care, initiated 06/10/23, revealed Resident #8 had potential/actual skin impairment related to fragile skin. Interventions included to follow facility protocols for treatment of injury. Review of the physician orders for November 2023 and December 2023 revealed an order to cleanse bilateral lower legs with soap and water, pat dry, and apply unna boots (compression dressings) to bilateral lower legs from toes to below the knee and change every Tuesday and Friday. Review of the Medication Administration Record (MAR) for 12/23 revealed Resident #8's unna boots treatment was not completed on 12/01/23, 12/05/23, 12/08/23 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, staff interview and review of facility policy, the facility failed to complete wound care treatments per physician orders. This affected one (#8) of three residents reviewed for wound care. The facility census was 80. Findings include: Review of the medical record for Resident #8 revealed an admission date of 06/09/23 with diagnoses including non-pressure chronic ulcer of left lower leg. Review of the plan of care, initiated 06/10/23, revealed Resident #8 had potential/actual skin impairment related to fragile skin. Interventions included follow facility protocols for treatment of injury. Review of the physician orders for November 2023 and December 2023 revealed an order to cleanse bilateral lower legs with soap and water, pat dry, and apply unna boots (compression dressing) to bilateral lower legs from toes to below the knee and change every Tuesday and Friday. Review of the Medication Administration Record (MAR) for November 2023 revealed no documentation Resident #8 was provided unna boots treatment on 11/10/23, 11/17/23, 11/21/23 and 11/28/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to ensure neurological checks were completely accurately after an unobserved fall. This affected three (#57, #66, and #84) of three residents reviewed for falls. Additionally, the facility failed to ensure neurological checks were completed after a resident alleged being struck in the head. This affected one (#85) of two residents reviewed for potential head injuries. The facility census was 80. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 08/24/22 with diagnoses of epilepsy and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had impaired cognition, had two or more falls without injury since the previous assessment and was independent for walking up to 150 feet. Review of the Fall Risk assessment dated [DATE] revealed Resident #57 was at moderate risk for falls. Review of the facility's incident log revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the staff schedule, the facility failed to ensure nurses charted and initiated physician orders with their own credentials. This affected one (#84) of one residents reviewed for an accurate medical record and had the potential to affect all other residents (#11, #17, #22, #33, #35, #37, #43, #49, #50, #58, #59, #69, #70, #74, #77,#80, and #91) on the first floor. The facility identified 18 residents on the first floor. The facility census was 80. Findings include: Review of the medical record for Resident #84 revealed an admission date of 03/09/17 with diagnoses of schizoaffective disorder, depression, and kleptomania. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had impaired cognition. Resident #84 resided on the first floor of the facility. Review of a progress note written by LPN #205 dated 12/20/23 at 2:15 P.M. revealed Resident #84 exhibited agitation and verbal behaviors. LPN #205 documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, review of the COVID-19 door postings, and review of the facility policy, the facility failed to ensure staff implemented infection control procedures regarding donning (putting on) and doffing (taking off) of Personal Protective Equipment (PPE) before entering and after exiting a room with an active case of COVID-19. This had the potential to affect 11 residents on the first floor who were not diagnosed with COVID-19 during the current outbreak (#17, #22, #35, #37, #43, #50, #59, #69, #70, #77, and #84). The facility census was 80. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/13/21 with diagnoses of schizophrenia, depression, and bipolar. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had intact cognition. Review of the medical record for Resident #80 revealed an admission date of 12/27/23 with diagnoses of anxiety and schizoaffective disorder. Review 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 review of the medical record, staff interview, resident interview, review of the self-reported incidents (SRI), and policy review, the facility failed to ensure an allegation of verbal abuse was reported to the state agency. This affected one (#79) of three residents reviewed for abuse. The facility census was 80. Findings include: Review of the medical record for Resident #79 revealed an admission date of 03/24/23. Diagnoses included hypertension, cerebral palsy, diabetes mellitus type two, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with activities of daily living. The resident had intact cognition. Review of the nurse's notes dated 10/18/23 at 5:30 P.M., revealed an incident note revealed the resident had reported an allegation of verbal abuse. Review of the facility self-reported incidents (SRI) revealed no SRI for verbal abuse had been reported for Resident #79. Review of a nurse's note dated 10/19/23 at 4:17 P.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.

Based on observation, staff interview, review of the dishwasher manufacturer manual, review of an email from the chemical supplier, review of food temperature logs, and review of facility policy, the facility failed to ensure foods were properly labeled and stored, failed to ensure the milk cooler was monitored for appropriate cooling temperature, failed to maintain food temperature logs, failed to ensure the dishwasher properly sanitized dishes, and failed to maintain a clean and sanitary kitchen. This had the potential to affect all 80 residents of the facility. The facility census was 80. Findings include: 1. Observation on 12/04/22 at 8:31 A.M. of the kitchen revealed Dietary Aide (DA) #180 washing dishes using the facility dishwasher. Interview with DA #180 at the time of the observation revealed she was unsure if the dishwasher used high temperature or chemical sanitizing. Continued observation confirmed the dishwasher utilized chlorine chemical sanitizing. DA #180 was uncertain where the chlorine test strips were located, had to look for them and returned with test strips 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 observation, staff interview, and review of facility policy the facility failed to ensure effective pest control was maintained. This has the potential to affect all residents residing at the facility. The facility census was 80. Findings include: Observations on 12/04/22 at 12:00 P.M., on 12/05/22 at 1:00 P.M. and again on 12/06/22 at 12:00 P.M. revealed small black bugs flying in the beauty shop and several black bugs, which appeared to be dead on the white window seal and on the grey window ledge. Observation on 12/06/22 at 12:00 P.M. revealed the Administrator swatting away the black bugs flying near their face. Interview on 12/06/22 at 12:00 P.M. with the Administrator verified the flying small black bugs in the beauty shop and further verified the window seal and grey window ledge were covered in what appeared to be dead bugs. The Administrator also verified all residents use the beauty shop either to be weighed or to get hair done. Review of the facility policy titled, Pest Control Program, dated 08/14/20 stated the facility was to maintain an effective pest control…

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 residents wishes for life-sustaining treatment was clearly reflected in the medical record. This affected nine (Residents #18, #19, #47, #48, #64, #72, #77, #80, #82) of 24 residents reviewed for advanced directives. The facility census was 80. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included emphysema, hypokalemia, type II diabetes mellitus, and hypertension. Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Resident #19 was independent for the activities of daily living (ADL). Review of Resident #19's physician orders, identified an order dated [DATE] for cardiopulmonary resuscitative (CPR). Review of Resident #19's medical record revealed Resident #19 was identified as having a CPR code status. Interview on [DATE] at 2:48…

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

Based on observation, review of the facility menu, and staff interview, the facility failed to follow the approved menu. This affected 12 (Residents #11, #13, #17, #30, #32, #36, #41, #43, #44, #46 #65 and #76) of 12 residents observed for dining. The facility census was 80. Findings include: Observation on 12/04/22 at 11:15 A.M. of lunch tray line service revealed the lunch meal consisted of sliced ham, stuffing and mixed vegetables. Dietary Aide #180 plated the meal and placed the meals in carts for transport to the designated areas. Carts one and two left the kitchen for delivery to residents. No other food was on the meal trays. Review of the dietary menu dated 12/04/22 revealed the approved lunch meal was baked ham, stuffing, green beans and pears. Interview on 12/04/22 at 11:35 A.M. of Dietary Manager (DM) #163 verified residents were not served pears on their meal carts. DA #180 stated it was the responsibility of other dietary staff to ensure resident meal trays included pears. DM #163 went to the dry storage room and returned to the kitchen with applesauce cups and began…

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

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected five (Residents #6, #14, #25, #33 and #73) of five residents reviewed for environment with the potential to affect all residents residing in the facility. The facility census was 80. Findings include: 1. Observation on 12/04/22 at 8:03 A.M. of Resident #73's room revealed a round hole approximately two and half inches in diameter in the wall, even with the height of resident's bed. Interview on 12/05/22 at 8:16 A.M. with Licensed Practical Nurse (LPN) # 181 verified the hole in the wall in Resident #73's room. 2. Observation on 12/04/22 at 11:57 A.M. revealed dust and debris on the flat surfaces of the red fire alarm box, call light boxes outside of rooms, and white carbon monoxide boxes in the hallways. Additional observations revealed a thick layer of dust on the grates of the ceiling vents outside Resident #13 and Resident #60's room and Resident #80 and Resident #69's room. Interview on 12/05/21 at 8:21 A.M. of Housekeeper #158 revealed all flat services in…

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

Based on observation, staff interview, and review of facility policy, the facility failed to ensure smoking safety was maintained. This affected 14 individuals observed for smoking and had the potential to affect all residents residing at the facility. The facility census was 80. Findings include: Observation on 12/05/22 at 4:05 P.M. of Residents #12, #13, #17, #18, #32, #35, #39, #51, #53, #60, #69, #74, #75 and #80 lined up in the hallway of Station 2 to the dining room revealed each resident approached a table to the right of the door upon entering the dining room, were provided a cigarette. State Tested Nursing Assistant (STNA) #180 proceeded to use a lighter and lit each resident's cigarettes (inside the facility). Each of the resident, with a lit cigarette in their mouth, walked approximately 15 feet and entered the Station 2 smoking room. The smoking room door was opened to the dining room and remained open throughout the duration of the residents smoking. STNA #180 did not enter the smoking room to supervise smoking residents. Interview with STNA #180 at the time 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.

Based on medical record review and staff interview, the facility failed to complete a discharge Minimum Data Set (MDS) 3.0 assessment for Resident #70 as required. This affected one resident (Resident #70) of two discharged residents reviewed. The facility census was 80. Findings Include: Medical record review for Resident #70 revealed an admission date of 03/02/18. Diagnoses included seizures, cirrhosis of the liver, chronic obstructive pulmonary disease, anemia, schizoaffective disorder, major depressive disorder, dementia, hypertension, chronic viral Hepatitis C, and hyperlipidemia. Review of the progress notes for Resident #70 revealed the resident was discharged to another facility on 07/13/22 at 12:02 P.M. Review of Resident #70's MDS assessment history revealed the most recent MDS was completed on 06/26/22, which was a quarterly assessment. There was no evidence a discharge MDS assessment was completed. Interview on 12/07/22 at 1:15 P.M. with the Corporate [NAME] President of Clinical Operations verified the discharge MDS was not completed for Resident #70 and the electronic…

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, and staff interviews, and review of facility policy, the facility failed to ensure skin assessments were completed accurately and failed to ensure physician ordered devices were available for Resident #49. This affected one (Resident #49) of one resident reviewed for foot care. The facility census was 80. Findings include: Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, hypertension, schizoaffective disorder, depression, and impulse disorder, insomnia. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/22, revealed the resident was cognitively intact. Resident #19 was independent for the majority of activities of daily living (ADL). Review of Resident #49's physician orders identified an order dated 11/15/22 for Darco shoe to be worn on right foot, and an order dated 11/16/22 to wash right foot with normal saline,…

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, review of meal tickets, and staff interview, the facility failed to provide supplements with meals as ordered. Additionally, the facility failed to have ordered supplements available. This affected three (Residents #65, #18, and #53) of three residents reviewed for nutritional supplements. The facility census was 80. Findings include: 1. Review of Resident #65's medical record revealed an admission date of 11/30/20 and a readmission date of 12/21/20. Diagnoses included anxiety disorder, mild protein-calorie malnutrition, rheumatoid arthritis, hypertension, major depressive disorder, syncope and collapse and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was moderately cognitively impaired, required supervision and set up assistance with eating, and had no significant weight loss. Review of the plan of care focus area revised 12/02/22 revealed Resident #65 had a potential nutritional problem related 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 review of facility policy, the facility failed to ensure oxygen was administered as ordered. This affected one (Resident #14) of one resident reviewed for oxygen administration. The facility identified seven residents who had physician orders for oxygen. The facility census was 80. Findings include: Review of Resident #14's medical record revealed an admission date of 01/12/10 and a readmission date of 04/20/18. Diagnoses included schizophrenia, morbid obesity, hypertension, type II diabetes, bipolar disorder, chronic obstructive pulmonary disease (COPD), asthma, atherosclerotic heart disease, post-traumatic stress disorder (PTSD) and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact, required supervision for eating and personal hygiene, was independent with toilet use, dressing, and required limited assistance with bed mobility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 one (Resident #47) of four residents reviewed for insulin administration. The facility census was 80. Findings include: Review of Resident #47's record revealed an admission date of 04/22/22. Diagnoses included Hallervorden-[NAME] disease, diabetes mellitus type II, chronic obstructive pulmonary disease, schizoaffective disorder, panic disorder, metabolic encephalopathy, major depressive disorder and hypotension. Review of a physician order dated 04/22/22 revealed Resident #47 was ordered insulin glargine 23 units subcutaneously (SQ) twice a day, in the morning and in the evening. Observation on 12/06/22 at 8:06 A.M. revealed Licensed Practical Nurse (LPN) #181 prepared to administer Resident #47 her morning medications. LPN #181 removed Resident #47's insulin glargine pen from the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and resident and staff interview, the facility failed to maintain accurate medical records. This affected one (Resident #49) of two residents reviewed for maintaining medical records. The facility census was 80. Findings include: Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, hypertension, schizoaffective disorder, depression, and impulse disorder, insomnia. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/22, revealed the resident was cognitively intact. Resident #19 was independent for a majority of the activities of daily living (ADL). Review of Resident #49's physician orders identified an order dated 11/15/22 for Darco shoe to be worn on the right foot. Review of Resident #49's Treatment Administration Records (TAR) for 11/15/22 through 12/04/22 revealed the resident was documented as wearing the Darco shoe on 11/15/22,…

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 the resident's advance directives were accurate in the medical record. This affected one (#30) of 27 residents reviewed for advance directives. The facility census was 84. Findings include: Review of Resident #30's medical record revealed an admission date of 10/28/14. Diagnoses included schizophrenia, abnormal posture, heart failure, vitamin D deficiency, anxiety, bipolar disorder, chronic obstructive pulmonary disease, and diabetes mellitus type II. Review of a Do Not Resuscitate Identification form, dated 11/25/17, revealed Resident #30's advance directives were for a Do Not Resuscitate, Comfort Care (DNRCC). The DNRCC was further explained as the comfort care protocol would be activated immediately. Review of a physician ordered dated 02/04/19 revealed Resident #30's code status was a DNRCC-Arrest indicating the comfort care protocol was not implemented unless there was a cardiac or a respiratory arrest. Interview on 10/30/19 at 11:54 A.M., Licensed Practical Nurse (LPN) #200…

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 were provided with timely advanced notices of Medicare skilled services being discontinued. This affected two (#70 and #282) of three residents reviewed for beneficiary notices. The facility identified four residents who were discharged from Medicare skilled services in the last 90 days. The facility census was 84. Findings include: 1. Review of the medical record for Resident #70 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, diabetes mellitus type II, chronic atrial fibrillation, heart failure, acute kidney failure, muscle weakness, hypertension, anemia, history of heart attack, chronic obstructive pulmonary disease, obesity and depression. Review of a Notice of Medicare Non Coverage form revealed the resident began receiving skilled services on 02/10/19 and the last coved day would by 05/20/19. The form was signed by the resident on 05/20/19. Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to verify placement of an gastrostomy tube prior to administering medications. This affected one (#14) of three residents observed during medication administration. The facility verified Resident #14 was the only resident who received medications via a gastrostomy tube. The census was 84. Findings include: Review of Resident #14's medical record revealed an admission date of 06/04/13. Diagnoses included Huntington's disease, contracture of muscle, dysphagia, constipation, anxiety, and unspecified convulsions. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severely impaired cognitive skills for daily decision making and was assessed with a gastrostomy feeding tube (a tube that is placed directly into the stomach). Review of a physician order dated 08/07/19 revealed nurses should check Resident #14's gastrostomy tube for residual tube…

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

Based on observation, resident and staff interviews, and medical record review, the facility failed to provide a comfortable mattress. This affected one (#30) of 27 resident's beds observed. The census was 84. Findings include: Review of Resident #30's medical record revealed an admission date of 10/28/14. Diagnoses included schizophrenia, abnormal posture, heart failure, vitamin deficiency, anxiety, bipolar disorder, chronic obstructive pulmonary disease, and diabetes mellitus type II. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 08/31/19, revealed Resident #30 was severely cognitively impaired and assessed with no pressure related skin conditions. Review of Resident #30's current physician orders dated between 02/04/19 and 10/31/19 revealed no physician order for an air mattress. Review of Resident #30's comprehensive care care plan with a revision date of 09/25/19 revealed no focus areas or interventions indicating the use of an air mattress. Review of Resident #30's most recent assessment to determine pressure sore risk revealed Resident #30 had…

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