Continuing Healthcare Of Toledo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure incontinence interventions were implemented in a timely manner and in accordance with nursing plans of care. This affected three (#1, #2, #3) of three sampled residents reviewed for incontinence care and treatment. Facility census was 69. Findings include: 1. Resident #1 admitted to the facility on [DATE] with diagnoses including, polyosteoarthritis, anemia, chronic fatigue, polyneuropathy, congestive heart failure, peripheral vascular disease, spondylosis, absence right leg above knee, and covid-19. According to the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 with severe cognitive impairment, dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and at risk for pressure ulcer development with no skin breakdown. On 09/20/24, a Bladder Incontinence Data Collection Tool was completed and noted resident 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 staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER) Report, the facility failed to have an effective quality assurance program to address repeated quality concerns identified during three consecutive annual surveys. This affected all 61 residents in the facility. The census was 61. Findings include: Review of the CASPER Report dated 08/02/24 revealed the facility received deficiencies for failing to provide activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. 1. Review of the medical record for Resident #24, during the current annual survey, revealed an admission date of 05/28/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and was dependent on staff for personal hygiene. Observations on 08/12/24 at 10:33 A.M., 08/13/24 at 3:57 P.M. and 08/14/24 at 3:20 P.M. revealed Resident #24's fingernails 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, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure the facility environment was maintained in a safe and sanitary manner. This affected five (#35, #36, #43, #46, and #47) of five residents reviewed for physical environment. The census was 61. Findings include: 1. Review of the medical record noted Resident #36 was admitted to the facility on [DATE] with the diagnoses including epilepsy, extended spectrum beta lactamase resistance, type II diabetes mellitus, hypertension, acute kidney failure, anxiety disorder, hypothyroidism, muscle wasting and atrophy, and dysphagia. Review of the current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #36 with moderately impaired cognition, and the resident required partial to moderate assist with activities of daily living including toileting, and was frequently incontinent of bowel and bladder. Observation on 08/12/24 at 11:15 A.M. noted Resident #36 room with a strong urine…

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

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure hand hygiene was practiced during meal service. This affected six (#24, #155, #160, #161, #162, and #154) of six residents observed during meal service. The facility census was 61. Findings include: Observation on 08/12/24 at 12:17 P.M. revealed a cart with lunch trays was delivered to the 300 hall. Observation on 08/12/24 at approximately 12:18 P.M. revealed Licensed Practical Nurse (LPN) #426 pushing Resident #40 in a wheelchair to the scale in the lounge. LPN #426 assisted Resident #40 by touching his sleeve while he stood on the scale and she obtained his weight. LPN #426 then assisted Resident #40 back into his wheelchair and pushed him back to his room. LPN #426 did not practice hand hygiene before opening the meal cart and removing Resident #24's meal tray. LPN #426 entered Resident #24's room, moved items from her overbed table, and set down Resident #24's meal on the table. Interview on 08/12/24 at 12:24 P.M. with LPN #426 confirmed she did not clean her hands after…

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, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected two (#47 and #155) of 30 residents reviewed for MDS assessments. The facility census was 61. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 06/30/22 with diagnoses of neoplasm of the brain and anxiety. Review of the annual MDS assessment dated [DATE] revealed Resident #47 had intact cognition and no functional limitations in range of motion to his upper extremity (shoulder, elbow, wrist, hand). Review of the physical therapy progress report and updated therapy plan dated 07/08/24 through 08/06/24 revealed Resident #47 was assessed on 07/07/24 and 07/08/24 and was found to have left shoulder range of motion from zero to 90 degrees, with standard range of motion defined as zero to 120 degrees. Interview and observation on 08/12/24 at 2:25 P.M. with Resident #47 revealed he had pain 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, resident interview, and staff interview, the facility failed to adequate ensure nail care was provided to residents dependent on staff for care. This affected two (#24 and #44) of three residents reviewed for assistance with activities of daily life (ADLs). The facility census was 61. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 05/28/24 with diagnoses of type II diabetes mellitus and anxiety. Review of the modified admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and was dependent for personal hygiene. Review of the current care plan for Resident #24 revealed she had an ADL self-care performance deficit. Interventions included checking nail length and trimming and cleaning on bath day and as necessary. Observation and interview on 08/12/24 at 10:33 A.M. with Resident #24 revealed the nails on her left hand were long and had dark debris under them. Resident #24 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, review of the medical record, review of a bowel protocol, and review of a facility policy, the facility failed to ensure wound dressings were completed per physician orders and failed to implement the facility bowel protocol as indicated. This affected one (#155) of two residents reviewed for wounds and two (#24 and #49) of two residents review for bowel movements. The facility census was 61. Findings include: 1. Review of the medical record for Resident #155 revealed an admission date of 07/26/24 with a diagnosis of a wound to the right forearm. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #155 had intact cognition. Review of a physician order dated 07/26/24 revealed wound care orders to wash Resident #155's right forearm with normal saline, pat dry, cover the wound bed with collagen, then place adaptic over collagen, cover with foam, and change daily and as needed to be completed every day shift and as needed for wound 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 observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were adequately supervised while smoking and failed to ensure smoking materials were maintained in a safe manner. This affected two (#21 and #156) of two residents reviewed for smoking. The facility census was 61. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 04/09/24 with diagnoses of bipolar disorder, dementia, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/24, revealed Resident #21 had impaired cognition. Review of the smoking safety screen document, dated 04/10/24, revealed Resident #21 required supervision while smoking. Observation on 08/13/24 at 10:43 A.M. revealed five residents in the smoking area, including Resident #21, and no facility staff. Resident #21 was smoking two cigarettes at the same time, with one in each hand. Resident #21 was sitting in a wheelchair wearing…

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 review, the facility failed to ensure timely incontinence care and interventions were provided following an episode of urinary incontinence. This affected one (#36) of three residents reviewed for urinary tract infections in a facility census of 61. Findings include: Review of the medical record noted Resident #36 admitted to the facility on [DATE] with diagnoses including, epilepsy, extended spectrum beta lactamase resistance, type II diabetes mellitus, hypertension, acute kidney failure, anxiety disorder, hypothyroidism, muscle wasting and atrophy, and dysphagia. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was assessed with moderately impaired cognition, required partial to moderate assist with activities of daily living (ADLs) including toileting, and was frequently incontinent of bowel and bladder. Review of Resident #36's care plan revealed on 09/10/21 a nursing plan of 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 observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed during personal care and failed to ensure appropriate infection control procedures were practiced. This affected one (#24) of one residents reviewed for enhanced barrier precautions. The facility census was 61. Findings include: Review of the medical record for Resident #24 revealed an admission date of 05/28/24 with diagnoses of type II diabetes mellitus and anxiety. Review of the modified admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and was always continent of bowel and bladder and was dependent for toileting and personal hygiene. Review of the current care plan for Resident #24 revealed she had an activities of daily living (ADL) self-care performance deficit and was dependent on staff for toileting and personal hygiene. Review of Resident #24's care plan dated 05/30/24, and current…

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 of vaccinations, staff interview, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to offer COVID-19 booster vaccines for residents as indicated. This affected three (#12, #15, and #34) of five reviewed for COVID-19 vaccinations. The facility census was 61. Findings include: 1. Review of the medical record for Resident #12 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #12 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022. 2. Review of the medical record for Resident #15 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #15 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022. 3. Review of the medical record for Resident #34 revealed the last administration of COVID-19 vaccination was 08/19/22.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure the facility had an effective pest control program to promote an environment that was free from pests. This affected one (#36) of five residents reviewed for the environment. The census was 61. Findings include: Review of the medical record noted Resident #36 was admitted to the facility on [DATE] with diagnoses including, epilepsy, extended spectrum beta lactamase resistance, type II diabetes mellitus, hypertension, acute kidney failure, anxiety disorder, hypothyroidism, muscle wasting and atrophy, and dysphagia. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #36 with moderately impaired cognition, required partial to moderate assist with activities of daily living including toileting, and was frequently incontinent of bowel and bladder. Observation on 08/12/24 at 11:15 A.M. noted Resident #36's room with a lift pad (cloth chux) bed linen with 16 gnats on the surface 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 observations, resident and staff interview, and policy review, the facility failed to maintain a homelike and clean environment for residents. This affected 20 resident rooms (#103, #109, #110, #111, #114, #115, #116, #117, #118, #119, #121, #122, #123, #125, #126, #127, #208, #210, #216, and #221) of 51 resident rooms. The facility census was 53. Findings included: 1. Observations on 07/25/22 at 10:41 A.M. of room [ROOM NUMBER] revealed the resident's bathroom door had an approximate three-inch round hole, the walls were scuffed and missing paint, and the floor strip between the bathroom and main area was missing. Observation on 07/25/22 at 11:10 A.M. of room [ROOM NUMBER] revealed the walls were scuffed with black marks along the floor and half-way up the wall. There were towels laying on top of the sheets on the resident's bed and the towels were stained with a dark brown oval area approximately 12 inches by five inches. The wall to the left of the bathroom had vinyl trim which was dirty and coming…

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 interview, and staff interview, the facility failed to ensure Resident #44 received showers per his preference. This affected one (Resident #44) of three residents reviewed for choices. The facility census was 53. Findings include: Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Review of Resident #44's admission Minimum Data Set (MDS) 3.0 assessment, dated 06/17/22, revealed the resident was cognitively intact. Resident #44 was totally dependent on the assistance of one staff for bathing. Resident #44 did not refuse or resist care. Review of Resident #44's plan of care, dated 07/08/22, revealed the resident had an activities of daily living (ADL) self-care performance deficit due to limited mobility and dependent status. Interventions included the resident was totally dependent on staff to provide bath/shower two 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 on record review, review of resident funds, staff interview, and review of the facility's policy, the facility failed to ensure a resident's funds was returned to the estate within 30 days of the resident's death. This affected one (Resident #256) of three residents reviewed for funds. The facility census was 53. Findings include: Review of Resident #256's medical record revealed she expired in the facility on [DATE]. Review of Resident #256's Resident Fund Management Service authorization and agreement dated [DATE] revealed in th event of Resident #256's death, Resident #256 directs that any funds owed or advanced to Resident #256 by the facility prior to my death were to be paid to the facility with any remaining balance in the resident fund account to become part of my estate. Review of the facility's account statement dated [DATE] revealed Resident #256 had funds in the account totaling $3,829.25. Interview with Human Resource Manager #76 on [DATE] at 3:11 P.M. verified Resident #256's funds remained…

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 Resident 26's advance directive information was complete. This affected one (Resident #26) of nine residents reviewed for advanced directives. The facility census was 53. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the physician's order dated [DATE] revealed Resident #26 had an order for Do Not Resuscitate Comfort Care (DNRCC) code status signifying cardiopulmonary resuscitative (CPR) measures were not to be conducted in case of cardiac or respiratory arrest. Review of Resident #26's paper medical record revealed a Do Not Resuscitate form dated [DATE]. The form indicated Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) or DNRCC should be marked and neither code status…

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 bed hold notices were given to residents upon discharge to the hospital. This affected one (Resident #31) of two residents reviewed for hospitalization. The facility census was 53. Findings include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, hepatitis b, chronic obstructive pulmonary disease, and congestive heart failure. Review of the census records for Resident #31 revealed the resident was discharged to a local hospital on [DATE] and returned to the facility on [DATE]. Resident #31 was discharged to the hospital again on 06/09/22 and returned to the facility on [DATE]. Review of both the electronic and hard charts revealed no evidence Resident #31 was given a bed hold notice for the discharges to the hospital on [DATE] and 06/09/22. Interview on 07/27/22 at 12:07 P.M. with the Administrator verified there was no evidence Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately for Residents #25 and #57. This affected two (#25 and #57) of nineteen residents whose MDS assessments were reviewed. The facility census was 53. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 09/03/20. Diagnoses included type II diabetes mellitus, depression, anxiety, respiratory failure, and heart failure. Review of Resident #25's physician orders dated 02/10/22 revealed an order for oxygen at four liters per minute via nasal cannula continuously. Review of the Treatment Administration Record (TAR) for July 2022 revealed Resident #25 received oxygen throughout the month per physician order. Review of the quarterly MDS assessment dated [DATE] and the significant change MDS assessment dated [DATE], revealed Resident #25 did not utilize oxygen. Interview on 07/27/22 at 12:27 P.M. with Licensed…

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 interview, staff interview, and policy review, the facility failed to complete activities of daily living (ADL) for residents who required assistance on staff for assistance with bathing/showering. This affected two (#14 and #24) of three residents reviewed for ADLs. The facility identified 44 residents who required assistance from staff with bathing/showering. The facility census was 53. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 08/29/19. Diagnoses included coronary artery disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, cerebral vascular accident, chronic kidney disease, and hemiplegia and hemiparesis of the right side. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #14 had a high cognitive function. He required a one person physical assist for bathing and personal hygiene. Review of the care plan revealed Resident #14 required total assistance by 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 observations, record review, staff interview, and policy review, the facility failed to administer medication as physician ordered resulting in medication errors exceeding five percent. There were five medication errors out of 29 medications opportunities or a medication error rate of 17.24%. This affected two (Residents #48 and #52) of six residents reviewed observed for medication administration. The facility census was 53. Findings include: 1. Review of Resident #48's medical record revealed an admission date of 06/17/19. Diagnoses included schizophrenia, epilepsy, diabetes mellitus, acute kidney failure, and paranoid personality disorder. Review of Resident #48's physician order dated 06/28/22 revealed an order for Risperdal (antipsychotic) one milligram (mg) to be administered by mouth two times a day for schizophrenia. An order dated 06/17/22 for sodium chloride (salt supplement) one gram was to be administered three times a day for muscle contractions. Review of Resident #48's Medication Administration Record (MAR) dated July 2022 revealed the medications were to be…

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, observation of the medication cart, review of the facility's policy for medication storage, and review of insulin manufacturer instructions, the facility failed to ensure insulin products were marked with open dates. This affected two of the three medication carts observed for drug storage. This affected three residents (Residents #00, #22 and #29). The facility census was 53. Findings include: Observation of the medication cart on 07/28/22 at 10:25 A.M. revealed seven insulin pens with three of the insulin pens without an open date. Three vials of insulin, one insulin vial without an open date. Interview during this observation with Licensed Practical Nurse (LPN) #71 confirmed the insulin products, three insulin pens and one insulin vial were open and in use, but not marked with open dates for Residents #00, #22 and #29. LPN #71 stated an insulin product should be marked with an open date at the time it was initially opened for use and discarded after one month. Review of an undated facility policy titled Medication Storage confirmed medications shall be…

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 there was documentation of completion of physician's orders. This affected one (Resident #36) of nineteen residents review accuracy of medical records. The facility census was 53. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute chronic respiratory failure with hypoxia, tracheostomy, and disorder of the muscle. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 had problems with long- and short-term memory, difficulty communicating and was hard to understand. Resident #36 required total assistance with all care, included was oral care, tracheostomy care and suctioning. Review of the physician's order dated 03/28/22 revealed an order for Resident #36's head of bed to elevated at least thirty degrees. Review of Resident #36's treatment administration record for July 2022 revealed no evidence the head of the bed…

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

Based on observation, staff interview and review of the facility's policy, the facility failed to ensure proper infection control practices and procedures were in place when administering medications to residents. This affected three (Residents #37, #49 and #50) of 29 residents observed for medication administration. The facility census was 53. Findings include: Observations on 07/28/22 from 10:28 A.M. to 10:52 A.M. of medication administration completed by Licensed Practical Nurse (LPN) #71 revealed the following: • At 10:28 A.M. medications for Resident #49 were removed from pill cards by LPN #71. LPN #71 did not remove the pill cards from the drawer in the medication cart. LPN #71 pushed each pill from each of the pill cards with the right hand and caught each pill between the bare first finger and bare thumb of the left hand then placed each pill into the medication cup sitting on top of the medication cart. LPN #71 then walked with medication cup of pills into Resident #49's room, administered the medications to Resident #49 and walked back to the medication cart, unlocked 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 review of facility staffing schedules, staff interview and review of a facility policy, the facility failed to ensure they were adequately staffed when the facility failed to schedule a Registered Nurse (RN) for a minimum of eight consecutive hours, seven days a week. This had the potential to affect all 53 residents of the facility. Findings include: Review of facility staffing schedules revealed the facility did not have a RN scheduled for a minimum of eight consecutive hours on 07/04/19. Interview on 08/07/19 at 8:33 A.M., with the Medical Records (MR) #106, revealed she was responsible for the nursing staff scheduling, and confirmed the facility did not schedule a RN to work on 07/04/19. Interview on 08/07/19 at 9:20 A.M., with the Administrator confirmed the facility did not have a RN work for eight consecutive hours on 07/04/19. Review of the facility's undated policy titled Staffing Policy revealed the facility will provide sufficient nursing staff.

Based on personnel file review, and staff interview, the facility failed to ensure two State Tested Nursing Assistants (STNAs)( #129 and #145) of five reveiwed received 12 hours of inservice education annually. This had the potential to affect all 53 residents of the facility. Findings include: 1. Review of STNA #129's personnel file revealed the STNA was hired on 01/24/04. There was no evidence the STNA received any inservice education from 01/2018 and 09/2018. The STNAs signature of attendance was noted on six inservice sign-in sheets between 10/2018 and 01/2019, for a total of 5.25 hours of inservice education in the STNA's employment year. 2. Review of STNA #145's personnel file revealed the STNA was hired on 06/18/79. There was no evidence the STNA received any inservice education between 06/2018 and 09/2018. STNA #145's signature of attendance was noted on 10 inservice sign-in sheets between 10/2018 and 06/2019, for a total of 10 hours of inservice education in the STNA's employment year. The Human Resource Manager (HRM) #119 was interviewed on 08/07/19 at 10:27 A.M., 12:20…

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, staff interview, and review of facility policy, the facility failed to ensure residents were provided the opportunity to participate in the care planning process and have their care plans reviewed and revised for accuracy. This affected 14 (#2, #3, #14, #15, #16, #20, #26, #36, #38, #39, #43, #44, #49, and #50) of 22 residents reviewed for care plans. The facility census was 53. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 04/20/18. Diagnoses included hypertension, muscle weakness, atrial fibrillation, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, gastro-esophageal reflux disease without esophagitis, neuromuscular dysfunction of bladder, encephalopathy, schizophrenia, anemia, constipation, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/29/19, revealed Resident #26 was cognitively intact.…

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 observations, interview with facility staff, and review of facility policy, the facility failed to properly store and label medications in the 100 and 200 hall carts. This affected two of two medication carts observed. The facility census was 53. Findings include: Observation and simultaneous interview on 08/06/19 at 2:16 P.M. with Licensed Practical Nurse (LPN) #165 revealed the following medications unlabeled and not in their prescribed containers inside the medication cart: three 20 milligram (mg) Atorvastin (a lipid-lowering agent) pills, two 40 mg Atorvastatin pills, one 40 mg Furosemide (a diuretic), one 500 mg Metformin (an anti-diabetic), three 5mg Flexeril (a muscle relaxant), one 2 mg Glimepiride (an anti-diabetic), two 50 mg Mirtazapine (an anti-depressant), one Metoprolol (a beta-blocker) at an unknown dosage, and one Protonix (a proton pump inhibitor). Observation and simultaneous interview on 08/06/19 at 2:27 P.M. with Agency LPN #302 revealed revealed the following medications unlabeled and not in their prescribed containers inside the medication cart: two…

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 ensure food was stored properly when staff failed to cover 40 slices of cheesecake that was stored in the walk-in cooler. This had the potential to affect all residents in the facility except for 17 (#43, #48, #29, #25, #53, #50, #44, #14, #47, #2, #46, #31, #39, #106, #104, #103, and #33) residents identified by the facility who did not receive a piece of cheesecake. The facility census was 53. Findings include: Observation of the facility kitchen on 08/04/19 at 8:46 A.M., revealed there were 40 individual plates of cheesecake sitting on a rack in a walk-in cooler. The pieces of cheesecake were exposed and not covered nor was the rack covered. Interview on 08/04/19 at 9:02 A.M., Dietary [NAME] (DC) #153 revealed all food items were supposed to be covered when stored in the walk-in cooler. DC #153 verified there were 40 individual plates of cheesecake sitting on a rack in the walk-in cooler, uncovered.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to notify the physician of a change in skin condition for one (#38) of two residents reviewed for skin conditions. The facility identified five resident's with non-pressure skin conditions. The facility census was 53. Findings include: Review of the medical record for Resident #38 revealed an admission date of 12/05/18. Diagnoses include type 2 diabetes mellitus, hypertension, cerebral infarction, major depressive disorder, muscle weakness, altered mental status, and chronic ischemic heart disease. Review of the Minimum Data Set assessment, dated 07/06/19, revealed Resident #38 was cognitively intact. Resident #38 had an unhealed unstageable pressure ulcer, a pressure reducing device for chair, and a pressure reducing device for the bed. Resident #38 required extensive assistance of two person for bed mobility and transfers. Resident #38 required extensive assistance of one person for personal hygiene and toilet use. Review of the care plan, dated…

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

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to maintain the environment free from offensive odors for one (Resident #26) of 22 resident bathrooms in the final sample. In addition the facility failed to follow their policy to locate missing personal property for one (#14) of three sampled residents. The facility census was 53. Findings include: 1) Review of the medical record for Resident #26 reveals an admission date of 04/20/18. Diagnoses included hypertension, muscle weakness, atrial fibrillation, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, neuromuscular dysfunction of bladder, encephalopathy, schizophrenia, anemia, constipation, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/29/19, revealed Resident #26 was cognitively intact. Resident #26 was on a toileting program for bowel and bladder and was always continent of urine and was occasionally incontinent of bowel.…

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, review of Self-Reported Incidents (SRI), staff interview, review of facility investigations, and review of facility policy, the facility failed to implement their abuse policy to investigate allegations of abuse and injuries of unknown origin and failed to report these allegations to the State Survey Agency. This affected three (#19, #15, #53), of four residents reviewed for abuse. The facility census was 53. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 02/12/13. Diagnoses included atrial fibrillation, bacteremia, edema, osteomyelitis, shortness of breath, heart disease, diabetes, hypertension, cerebral infarction, anemia, acquired absence of leg below the right knee, spinal stenosis, chronic hepatitis, and major depressive disorder. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 06/21/19, revealed Resident #60 was cognitively intact. Interview on 08/04/19 at 1:43 P.M., Resident #19 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, review of Self-Reported Incidents (SRI), staff interview, review of facility investigations, and review of facility policy, the facility failed to report these allegations of abuse and injuries of unknown origirn to the State Survey Agency. This affected three (#19, #15, #53), of four residents reviewed for abuse. The facility census was 53. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 02/12/13. Diagnoses included atrial fibrillation, bacteremia, edema, osteomyelitis, shortness of breath, heart disease, diabetes, hypertension, cerebral infarction, anemia, acquired absence of leg below the right knee, spinal stenosis, chronic hepatitis, and major depressive disorder. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 06/21/19, revealed Resident #60 was cognitively intact. Interview on 08/04/19 at 1:43 P.M., Resident #19 revealed the previous Friday night, 08/02/19, Resident #19 had an incident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, review of Self-Reported Incidents (SRI), staff interview, review of facility investigations, and review of facility policy, the facility failed to investigate allegations of abuse. This affected two (#19 and #53), of four residents reviewed for abuse. The facility census was 53. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 02/12/13. Diagnoses included atrial fibrillation, bacteremia, edema, osteomyelitis, shortness of breath, heart disease, diabetes, hypertension, cerebral infarction, anemia, acquired absence of leg below the right knee, spinal stenosis, chronic hepatitis, and major depressive disorder. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 06/21/19, revealed Resident #60 was cognitively intact. Interview on 08/04/19 at 1:43 P.M., Resident #19 revealed the previous Friday night, 08/02/19, Resident #19 had an incident with a staff member. Resident #19 stated the staff member was physically…

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 medical records and staff interview, the facility failed to accurately assess behaviors on the Minimum Data Set (MDS) assessment for one (#53) of 22 residents reviewed for accurate MDS assessments. The census was 53. Findings include: Review of Resident #53's medical record revealed she admitted to the facility on [DATE]. Diagnoses included cerebral infarction, epilepsy, gout, major depressive disorder, type two diabetes and dementia without behavioral disturbance. Resident #53 discharged [DATE]. Review of a nursing note dated 05/04/19 revealed Resident #53 was intoxicated and was in the hallway cussing at the nurses. Resident #53 was then observed entering other resident rooms and demanding they eat the food on their tray or else. Resident #53 continued yelling and cussing down the hallway at the nurses. The local law enforcement was called and Resident #53 was removed from the facility for the evening. The on-call nurse was notified. Review of the discharge Minimum Data Set (MDS) assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to ensure residents with impaired verbal communication had assistive devices available to assist with communicating their wants and needs. This affected one (#47) of one resident reviewed for communication. The facility identified one resident with tracheostomy status and impaired communication. In addition, the facility failed to provide necessary services to prevent a decline in activities of daily living (ADL) for one (#3) of 22 residents reviewed for a decline in ADLs. The facility census was 53. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 09/30/16. Diagnoses included muscular dystrophy, respiratory failure with hypoxia, dependence on respirator, disorder of muscle, anxiety disorder, aphasia, anemia, motor and sensory neuropathy, dysphasia, tracheostomy, hyperlipidemia, schizoaffective disorder, and major depressive disorder. Review of Resident #47's Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, review of the medical record, and staff interview, the facility failed to provide fingernail care for two(#3 and #49) of 22 residents reviewed for activities of daily living (ADL) care. The facility census was 53. 1. Review of Resident #3's medical chart revealed he admitted to the facility on [DATE]. Diagnoses included quadriplegia, muscle spasm, shortness of breath, muscle weakness, and chronic pain. Review of Resident #3's Minimum Data Set (MDS) assessment, dated 07/29/19, revealed he was cognitively intact and dependent on staff for ADLs. Observations on 08/04/19 at 11:59 A.M., and 08/05/19 at 11:57 A.M., revealed Resident #3 had extremely long fingernails with dirt under them. Interview on 08/04/19 at 11:59 A.M., Resident #3 stated staff helps him with his nails if they notice they are long. Interview on 08/05/19 at 11:57 A.M., State-Tested Nursing Assistant (STNA) #129 stated the STNAs are responsible for cutting nails unless the resident is diabetic. She verified…

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, observation, resident interview, and staff interview, the facility failed to apply compression stockings per physician order for one (#26) of one sampled residents for edema. The facility census was 53. Findings include: Review of the medical record for Resident #26 revealed an admission date of 04/20/18. Diagnoses included hypertension, muscle weakness, atrial fibrillation, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, encephalopathy, schizophrenia, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/29/19, revealed Resident #26 was cognitively intact. Resident #26 had a diagnosis of hemiplegia and hemiparesis coded. Resident #26 extensive assistance with one person staff for dressing. Review of the physician orders revealed an order dated 04/04/19 for 20-30 medium/large full toe below knee compression stockings. Resident to wear daily and may remove at bedtime. Review of the care plan dated 04/20/18 revealed Resident #26 had 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 medical record review and staff interview, the facility failed to follow recommendations by the optometrist for one (#49) of 22 residents reviewed for appropriate assistive devices. The facility census was 53. Findings include: Review of Resident #49's medical record revealed he admitted to the facility on [DATE]. Diagnoses included hypertension, constipation, prostatic hyperplasia, major depressive disorder, shortness of breath, dementia without behavioral disturbance, anxiety disorder and chronic obstructive pulmonary disease. Review of Minimum Data Set assessment, dated 07/17/19, revealed Resident #49 had a severe cognitive impairment. Review of a vision consult, dated 05/02/19, the optometrist had written a referral for Resident #49 to have his cataracts removed. The note indicated if the resident does not go through with the procedure to order eye glasses. The prescription was included in the consultation. Review of a nursing note date 06/14/19 revealed Resident #49 refused to have his scheduled…

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 medical record, observation, resident interview, physician interview, and staff interview, the facility failed to provide appropriate foot care for one (Resident #20) of 22 residents reviewed for appropriate foot care. The census was 53. Findings include: Review of Resident #20's medical record revealed she admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, arthritis, and type two diabetes. Review of the Minimum Data Set assessment, dated 06/23/19, revealed Resident #20 was cognitively intact and required extensive assistance with activities of daily living. Review of Resident #20's care plan, last revised 01/28/19, revealed she should have podiatry consults as needed. Review of admission documentation revealed Resident #20 consented to podiatry services. Observation on 08/04/19 at 1:03 P.M. revealed Resident #20's right great toe was very thick and discolored and her toenails were very long. 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 medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure proper infections control procedures were used during tracheostomy care. In addition, the facility failed to ensure tracheostomy care was provided as ordered. This affected one resident (#47) of one reveiwed for tracheostomy care. The facility census was 53. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 09/30/16. Diagnoses included muscular dystrophy, respiratory failure with hypoxia, dependence on respirator, and major depressive disorder. Review of Resident #47's care plan revised 06/28/19 revealed supports and interventions for alteration in respiratory function related to oxygen use, tracheostomy, muscular dystrophy, schizophrenia, anxiety, and depression, and tracheostomy. Interventions for tracheostomy care included elevate head of bed for easier breathing, tracheostomy ties are secured at all times, monitor respiratory…

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 facility policy, the facility failed to ensure residents who received dialysis treatments had their dialysis fistulas monitored and weights completed as ordered. This affected two (#14, and #39) of two residents reviewed for dialysis. The facility identified four residents who received dialysis treatments. The facility census was 53. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 04/11/19. Diagnoses included major depressive disorder, atrial fibrillation, peripheral vascular disease, orthopedic aftercare following surgical amputation, secondary hyperparathyroidism of renal origin, chronic obstructive pulmonary disease, muscle weakness, unspecified type 2 diabetes mellitus with hyperglycemia, pressure ulcer of right heel, unspecified stage, metabolic encephalopathy, and hypertensive chronic kidney disease with end stage renal disease. Resident #14 received dialysis three times per week. Review of the quarterly Minimum Data Set (MDS) assessment, dated…

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

Based on medical record review, observation, staff interview, and policy review, the facility failed to prevent a medication error rate of less than five percent (%). This affected two residents (#7 and #39)of four observed for medication administration. There were 27 opportunities observed with four errors resulting in a 14.81% medication error rate. The facility census was 53. Findings include: Observation and interview on 08/06/19 at 8:25 A.M. of Licensed Practical Nurse (LPN) #165 revealed the LPN was administering medications to Resident #39. Medications administered included Flonase nasal spray 50 microgram (mcg) 0.05% one spray each nostril, Symbicort 80 mcg/4.5 mcg inhaler two puffs, and Levemir (insulin) via flex pen. LPN #165 did not prime the insulin pen prior to administering the 10 units of insulin, administered two sprays to each nostril, and the ordered the inhaler was unavailable for administration. The LPN verified the above errors. Observation and interview on 08/06/19 at 9:37 A.M. of LPN #302 during administration of medications to Resident #7 revealed the…

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

Based on observation, staff interview and facility policy review, the facility failed to ensure residents were free of any significant medication error. This affected one resident (#39) of one resident observed to receive insulin from an insulin pen. The facility identified five residents that receive insulin by an insulin pen. The facility census was 53. Findings include: Observation and interview on 08/06/19 at 8:25 A.M. revealed Licensed Practical Nurse (LPN) #165 verified an insulin pen with the medication order and dialed the insulin pen to ten units. LPN #165 did not prime the insulin pen with two units. LPN #165 preceded to administer ten units of Levemir insulin to Resident #39. The LPN verified she did not prime the insulin pen with two units prior to administering the ten units to Resident #39. Review of the policy titled Medication Administration dated 05/2016, revealed to always perform a safety test before each injection. Performing a safety test ensures that you get an accurate dose by ensuring the needle and pen work properly and removing air bubbles. Then select the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to identify conjunctivitis (pink eye)in one resident (#49) of three residents reviewed for infections. The facility census was 53. Findings include: Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including: hypertension, prostatic hyperplasia, and dementia without behavioral disturbance. Review of Resident #49's MDS, dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs). Review of Resident #49's care plan, last revised 07/18/19 revealed staff should monitor his eyes for signs and symptoms of infection. Observations of Resident #49 on 08/04/19 at 10:04 A.M., 08/05/19 at 9:31 A.M., 08/05/19 at 1:14 P.M., 08/05/19 at 5:40 P.M., and 08/06/19 at 7:25 A.M. revealed he had reddened eyes with drainage and his eyelashes were crusted together with drainage. Review of a physician order…

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