Divine Rehabilitation And Nursing At Toledo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to safely store medications. This affected one (#43) out of five residents reviewed for medication storage. The facility census was 60. Findings include:Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, arteriovenous malformation of the digestive system, paranoid schizophrenia, and disorganized schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #43 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Resident #43 was assessed with functional abilities to included supervision or touching assistance needed for showering/bathing, personal hygiene, upper and lower body dressing. Review of Resident #43's care plan last revised 02/27/26 revealed interventions allowing the resident to keep medications at bedside.…

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 ensure laboratory tests were completed per physician orders. This affected one (#23) of five residents reviewed for laboratory tests. The facility census was 60.Findings include:Review of the medical record for Resident #23 revealed an admission date of 07/14/20 with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status.Review of the quarterly Minimum Data Set assessment, dated 01/02/26, revealed Resident #23 had significantly impaired cognition, had a feeding tube, and relied on tube feeding to receive 51 percent (%) or more of nutrition and fluid needs. Review of the physician order dated 01/08/24 revealed Resident #23 received no food or water by mouth.Review of the physician order dated 10/03/24 and discontinued 02/26/26 revealed Resident #23 should have laboratory tests of a complete blood count (CBC) with differential, basic metabolic panel (BMP), and hemoglobin A1C every six months.Review of Resident #23's record revealed the most recent…

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 ensure skin assessments were completed accurately. This affected one (#48) of two people reviewed for skin assessments. The facility census was 60.Findings include:Review of the medical record for Resident #48 revealed an admission date of 09/16/25 with diagnoses including heart failure, acquired absence of the left leg above knee, type II diabetes mellitus, heart disease, and peripheral vascular disease. Resident #48 was admitted with an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to his right heel.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed Resident #48 had intact cognition and had one unstageable pressure ulcer.Review of Resident #48's skin grid pressure assessments dated 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/02/26, 02/09/26, and 02/16/26 revealed all the assessments were completed and signed by Wound Care Licensed Practical Nurse (LPN) #407 on 02/16/26. Interview on 03/03/26 at 3:37 P.M. with LPN #407 revealed she was new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital records, staff, pharmacist, and physician interview, and review of the facility policy, the facility failed to ensure residents were administered medications indicated for their medical diagnosis and free from unnecessary medications. This affected one (#39) of three residents reviewed for unnecessary medications. The facility census was 65.Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/24/25 and a discharge date of 12/22/25. Admitting diagnosis included Type I diabetes mellitus (T1DM) (a form of diabetes known as juvenile diabetes where the pancreas does not function at all in the production of insulin to control blood sugar levels in the body).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and had a diagnosis of T1DM and required insulin injections.Review of the diagnosis list for Resident #39 revealed a diagnosis of Type I diabetes mellitus…

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, review of pest control records, staff and resident interview, and review of the facility policy, the facility failed to ensure effective pest control in the facility. This affected two (#14 and #19) of three residents reviewed for pest control, and had the potential to affect all 71 residents residing in the facility. The facility census was 71.Findings include:Interview on 10/22/25 at 8:19 A.M. with Registered Nurse (RN) #307 revealed there were an excessive number of flies on the 100 and 200 halls. RN #307 stated the facility had fly swatters on the nurses' carts and in the residents' rooms due to the large number of flies in the facility.Interview on 10/22/25 at 8:55 A.M. with Licensed Practical Nurse (LPN) #301 revealed the facility had flies and gnats so bad that the nurses carried fly swatters during medication pass, and the residents that could use their hands had them in their room. LPN #301 stated there were times when staff would have to swat the flies away from resident's faces…

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 facility and oncology staff interview, the facility failed to follow pre-procedure physician orders to ensure the completion of a procedure. This affected one (#56) of three residents reviewed for completion of medical appointments. The facility census was 71. Findings include:Review of the medical record for Resident #56 revealed an admission date of 09/16/25. Diagnoses included heart failure, peripheral vascular disease, and acute respiratory failure.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Resident #56 was assessed to require total assistance with toileting, and substantial/maximal assistance with bathing, and was dependent for dressing and transferring in and out of bed.Review of the care plan dated 09/18/25 revealed Resident #56 was on anticoagulant therapy (apixaban) related to below the knee amputation. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, review of hospital documentation, staff interview, and review of facility policy, the facility failed to ensure timely assessment, measurement, and documentation of wound descriptions were completed and further failed to ensure physician ordered treatments and skin impairment interventions for a right heel pressure ulcer were initiated timely and completed as ordered. This affected one (#71) of three residents reviewed for pressure ulcers. The facility census was 71.Findings include:Review of the closed medical record for Resident #71 revealed an admission date of 08/01/25. Diagnosis included anemia, Type II diabetes mellitus, and chronic kidney disease. Resident #71 transferred to the hospital on [DATE] due to a change in condition and did not return to the facility.Review of the admission Minimum Data Set (MDS) assessment, dated 08/05/25, revealed Resident #71 was cognitively intact. Resident #71 was assessed to have one venous wound, one stage IV pressure ulcer, and 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 observed, review of facility's temperature log, review of facility policy, and staff interview, the facility failed to ensure all food was stored at appropriate temperatures. This has the potential to affect all residents with the exception of Resident #34 and Resident #19 (two residents identified as not receiving any food from the kitchen). The current census is 78. Findings include: Review of the facility's temperature logs dated August 2025 for the refrigerator revealed the lowest temperature for the refrigerator was recorded as 50 degrees with the highest temperature recorded was 65 degrees. Observation on 08/18/25 at 7:16 A.M. during a kitchen tour revealed the walk-in refrigerator temperature gauge read 50 degrees. During the observation there was no internal thermometer observed in the walk-in refrigerator. The walk-in freezer was in the back of the walk-in refrigerator and the outside temperature gauge for the freezer section was noted as -10 degrees. Ice was observed accumulating in the freezer around the fan. Interview on 08/18/25 at 7:16 A.M. with [NAME] #184…

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 hospital documentation, and staff interview, the facility failed to administer medications as ordered by the physician. This affected one (#34) of four residents reviewed for medication administration. The current census is 78.Findings include:Record review for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #34 include sepsis, heart failure, dysphagia, sepsis due to enterococcus, gastritis with a gastric ulcer, and encounter for palliative care. Review of Resident #34's comprehensive Minimum Data Set, (MDS) date 08/06/25 revealed the resident had impaired cognition and was receiving parental nutrition via a feeding tube. Review of Resident #34's progress notes dated from 08/11/2025 to 08/19/2025 revealed by the note dated 08/11/25 at 4:18 P.M. Resident #34 was having a choking episode and was transferred to the hospital for treatment. Review of Resident #34's hospital paperwork for discharge back to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a facility submitted Self-Reported Incident (SRI), resident and staff interview, review of the facility investigation, medical record review and review of the facility policy, the facility failed to ensure residents were free from neglect when Resident #01 was left outside overnight. This affected one (#01) of three residents reviewed for abuse and neglect. The facility census was 73. Findings include:Review of the medical record revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism (movement disorder), cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed Resident #01 was moderately cognitively impaired. Resident #01 was always incontinent of bowel and bladder and was (staff) dependent for toileting and chair to bed transfers. Review of the July 2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to report allegations of neglect timely to the State Survey Agency (SSA). This affected one (#01) of three residents reviewed for abuse and neglect. The facility census was 73. Findings include: Review of the medical record review revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed the resident was moderately cognitive impaired. Resident #01 was always incontinent of bowel and bladder and dependent on care for toileting and chair to bed transfers. Review of a nursing progress note, dated 07/13/25 at 6:59 A.M., revealed Resident #01 was not in his room at the time the writer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to ensure smoking assessments were completed for residents who smoked. This affected one (Resident #01) of three residents reviewed for smoking. The facility census was 73. Findings include:Review of the medical record revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed the resident was moderately cognitive impaired. Resident #01 was always incontinent of bowel and bladder and dependent on care for toileting and chair to bed transfers. Review of the care plan, dated 07/15/25, revealed Resident #01 was a smoker and interventions included to determine if the resident had a desire to quit, instruct resident on the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility submitted Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to ensure accurate medical records. This affected two (Resident #01 and #21) of three residents reviewed medical record documentation. The facility census was 73. Findings include:1) Review of the medical record revealed Resident #01 was admitted on [DATE]. Diagnoses included cerebral infarction (stroke), traumatic hemorrhage of cerebrum, difficulty in walking, anxiety disorder, unspecified urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence.Review of the Minimum Data Set (MDS) assessment, dated 04/25/25, revealed the resident was moderately cognitive impaired. Resident #01 was always incontinent of bowel and bladder and dependent on care for toileting and chair to bed transfers. Review of the July 2025 Medication Administration Record (MAR) revealed on the nightshift on 07/12/25, the following medications were…

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

Based on staff interview and review of facility staffing documentation, the facility failed to ensure a registered nurse (RN) worked for eight hours daily in the facility. This affected all 77 residents residing in the facility on 06/03/25. Findings include: Review of the facility staffing schedules dated 06/02/25 through 06/08/25 revealed the facility lacked a RN for eight consecutive hours on 06/03/25. Staffing schedules noted the lack of RN staffing coverage from the beginning of third shift on 06/02/25 until second shift on 06/04/25. Review of facility timekeeping daily staff punches on 06/03/25 lacked evidence indicating an RN was staffed in the facility. Review of the nursing staff information posting from 06/03/25 revealed the facility census was 77 residents. No RN coverage was listed on the nursing staff information posting during all three shifts. On 07/01/25 at 10:25 A.M., an interview with the Administrator verified there was no RN working eight hours consecutively in the facility on 06/03/25. This deficiency represents non-compliance investigated under Complaint Number…

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, observation, and review of facility policy, the facility failed to ensure timely incontinence care was provided and perineal care was provided to promote cleanliness. This affected one (#1) of three residents reviewed for the provision of incontinence care in a facility census of 73. Findings include: Medical record review revealed Resident #1 admitted to the facility on [DATE] with the diagnoses including, coronary artery disease, congestive heart failure, peripheral vascular disease, morbid obesity, and chronic kidney disease stage III. Review of the plan of care dated 10/01/20 revealed Resident #1 was incontinent of bladder and bowel related to decreased mobility and diuretic medications. Interventions included the resident utilized x-large disposable briefs. Change every two hours and as needed (PRN). Check every two hours and PRN for incontinence. Wash, rinse and dry perineum. Change clothing after incontinence care as needed. Provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, medical record review, review of personnel job descriptions, review of self-reported incidents (SRIs) and review of facility policies, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 79 residents residing in the facility. The facility census was 79. Findings include: 1) Review of Resident #100's medical record revealed the resident had a Full Code status. On [DATE], Resident #100 was found absent from vital signs. Licensed Practical Nurse (LPN) #300 did not initiate cardiopulmonary resuscitation (CPR), did not call for emergency medical services (EMS) assistance, and LPN #300 and LPN #501 subsequently called the resident's time of death without contacting the physician or any other provider qualified to call a resident's time of death.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and review of the facility policy the facility failed to ensure call lights were within residents' reach. This affected two (#3 and #11) of three residents reviewed for call lights. Additionally, the facility failed to ensure a sufficient supply of clean linens were available for resident use. This affected Resident #41 with the potential to affect all residents, except for 14 (#6, #23, #28, #35, #36, #38, #44, #45, #50, #51, #52, #60, #71, and #76) residents identified as residing on the secured memory care unit. The facility census was 79. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 11/13/19 with diagnoses of cerebral vascular accident (CVA - stroke), glaucoma, peripheral vascular disease (PVD), and heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and was dependent for toileting and personal hygiene. Review of the 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.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the environment was maintained in good repair. This had the potential to affect all residents, except 14 (#6, #23, #28, #35, #36, #38, #44, #45, #50, #51, #52, #60, #71, and #76) residents who resided on the secured memory care unit. The facility census was 79. Findings include: Observations on 05/06/25 at 2:10 P.M. of the hallways throughout the facility revealed a water stained ceiling tile surrounding a sprinkler head, wall paper peeling off the walls throughout the hallway, dirty stained flooring, and patches of flooring worn and discolored from use. Interview on 05/06/25 at 2:17 P.M. with Director of Maintenance (DOM) #369 verified the above findings. DOM #369 reported the sprinkler was no longer leaking, but the water stained ceiling tile could not be replaced until the sprinkler company replaced it. DOM #369 stated the date of service for the ceiling tile repair was unknown and further added it had been that way since he started at the facility approximately one and a half…

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 closed medical record review, staff interview, and review of facility policy the facility failed to notify the provider of a missed dose of total parenteral nutrition (TPN - intravenous delivery of nutrition) to a resident that required nutritional needs to be met by methods other than oral intake. This affected one (#101) of one resident reviewed for notification of change. The facility census was 79. Findings include: Review of the closed medical record for Resident #101 revealed an admission date of 04/17/25 and a discharge date of 05/04/25. Diagnoses included intestinal blockage, intestinal fistula (abnormal opening between the intestines and either the stomach or other parts of the body), colon cancer, hypertension (high blood pressure), and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment revealed it was not yet submitted. Review of the admission Assessment, dated 04/17/25, revealed Resident #101 was alert and oriented to person, place, time, and situation. Further review revealed the resident was admitted for TPN therapy from 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.

Based on observation, staff interview, resident interview and review of the facility policy, the facility failed to ensure residents had working lights in their rooms. This affected two residents (#3 and #11) of three residents reviewed for functional lights. The facility census was 79. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 11/13/19 with diagnoses of cerebral vascular accident (CVA-stroke), glaucoma, peripheral vascular disease (PVD), and heart disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/21/25, revealed Resident #3 was cognitively intact and staff dependent for toileting and personal hygiene. Review of the care plan, initiated 10/28/20, revealed Resident #3 had impaired vision function related to glaucoma. Interventions included to place items in field of vision, orient to surroundings, place personal items in a consistent location to ensure they are easy to find, and provide the resident with large print books or books on tape. Review of an optometry note, dated 05/29/24, revealed Resident #3…

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 2. Review of the medical record for Resident #100 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, prostate cancer, and hypertension with congestive heart failure. Review of the annual MDS assessment, dated [DATE], revealed Resident #100 had mild cognitive impairment. Further review of the MDS assessments revealed on [DATE], an assessment was completed for Resident #100's death in the facility. Review of a physician order dated [DATE] revealed Resident #100 had an order for Full Code status. Review of the care plan initiated [DATE] revealed Resident #100 had a Full Code status. Interventions included to call 911 for transport to a local hospital, initiate Cardiopulmonary Resuscitation (CPR) in the absence of a pulse, notify family and physician of changes in condition. Interview on [DATE] at 12:23 P.M. with LPN #300 verified she did not initiate CPR on Resident #100 when he was found to be not breathing and did not…

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 investigate an incident of resident elopement. This affected one (#53) of three residents reviewed for elopement. The facility census was 79. Findings include: Review of the medical record revealed Resident #53 was admitted on [DATE]. Diagnoses included angina pectoris, depression, schizoaffective disorder, anxiety disorder, unspecified osteoarthritis, iron deficiency anemia secondary to blood loss, and unspecified hearing loss. Review of the Minimum Data Set (MDS) assessment, dated 04/09/25, revealed the resident was cognitively intact. Review of the care plan, dated 02/05/25, revealed Resident #53 was an elopement risk/wanderer. Interventions included to assess for fall risk, check device (WanderGuard) for function and location every shift, distract resident from wandering by offering pleasant diversions (structured activities, food, conversation, television, and books), monitor for fatigue and weight…

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 the facility policy, the facility failed to ensure dependent residents received showers as scheduled and further failed to ensure dependent residents received assistance with all activities of daily living (ADLs) timely. This affected three (#39, #45, and #53) of five residents reviewed for ADLs. The facility census was 79. Findings include: 1. Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, chronic respiratory failure, chronic diastolic heart failure, essential hypertension, pure hypercholesterolemia, and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 04/04/25, revealed Resident #39 was cognitively intact and staff dependent for toileting, showering, lower body dressing, footwear, and personal hygiene. Review of the care plan, revised 02/17/25, revealed Resident #39 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.

Based on resident interview, staff interview, observation, review of the medical record and review of facility policy, the facility failed to ensure timely incontinence care. This affected one (#1) of three residents reviewed for incontinence care. The facility census was 79. Findings include: Review of the medical record for Resident #1 revealed an admission date of 09/18/20 with diagnoses of congestive heart failure (CHF), diabetes mellitus, and chronic kidney disease. Review of the quarterly MDS assessment, dated 03/31/25, revealed Resident #1 was cognitively intact and was dependent on staff for toileting and was incontinent of bowel and bladder. Review of the care plan, revised 11/24/20, revealed Resident #1 was incontinent of bowel and bladder. Interventions included resident used disposable briefs and check and change every two hours and as needed. Interview on 05/08/25 at 9:59 A.M. with Resident #1 revealed she was incontinent of urine and relied on the staff to change her. Resident #1 reported the last time she received incontinence are was at approximately at 5:00 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 closed medical record review, staff interview and review of the facility policy, the facility failed to ensure total parenteral nutrition (TPN - intravenous nutrition) was administered per physician orders. This affected one (#101) of two residents review for TPN. The facility identified two (#101 and #102) residents who required TPN administration for nutritional support. The facility census was 79. Findings include: Review of the closed medical record for Resident #101 revealed an admission date of 04/17/25 and a discharge date of 05/04/25. Diagnoses included intestinal blockage, intestinal fistula (abnormal opening between the intestines and either the stomach or other parts of the body), colon cancer, hypertension (high blood pressure), and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment for Resident #101 revealed it had not been submitted yet by the facility. Review of the admission Assessment, dated 04/17/25, revealed Resident #101 was alert and oriented to person, place, time, and situation. Resident #101 admitted for TPN therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included acute chronic systolic (congestive) heart failure, malignant neoplasm of prostate, cocaine use, major depressive disorder, and nonrheumatic aortic stenosis. Review of the MDS assessment, dated [DATE], revealed the resident was moderately cognitively impaired and required supervision assistance with toileting, shower/bathes, upper and body lower dressing, applying footwear, and personal hygiene. Review of a nursing progress note, dated [DATE] at 9:56 A.M., revealed Resident #49 complained of right hip pain when he moved. Resident #49 rated the pain as a 10 on a zero to 10 pain scale. The physician was notified and received an X-ray order for the right hip. An X-ray was completed. Review of a nursing progress note, dated [DATE] at 9:15 A.M., revealed X-ray results were received, the physician was notified, and an order was received to transport Resident #49 to the emergency room for evaluation. Review of the radiology…

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 adequate services were available to treat substance use disorders. This affected three (#49, #43, and #33) of three residents reviewed for substance use. The facility census was 79. Findings include: Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included acute chronic systolic (congestive) heart failure, malignant neoplasm of the prostate, cocaine use, major depressive disorder, and nonrheumatic aortic stenosis. Review of the MDS assessment, dated 02/08/25, revealed the resident was moderately cognitively impaired. Review of the care plan, dated 12/03/24, revealed Resident #49 had a history of substance use disorder as evidence by the use of cocaine. Interventions included administer medications as prescribed, assist in attending support groups, educate the resident on the risks of leaving the facility to seek out substances, encourage and allow the resident to express…

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 ensure insulin medications were administered per physician orders. This affected one resident (#27) of three residents reviewed for medication administration. The facility census was 79. Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/04/21 with a diagnosis of diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/12/25, revealed Resident #27 was cognitively intact and received insulin injections. Review of the care plan, initiated 10/22/21, revealed Resident #27 had type II diabetes mellitus. Interventions included diabetes medication as ordered by the physician. Review of the current physician orders revealed Resident #27 was ordered insulin glargine (long acting insulin to treat diabetes) subcutaneous solution pen-injector 100 unit (U)/ milliliter (ml), inject 50 U twice daily; insulin lispro (fast acting insulin, used to cover carbohydrates at mealtime, must eat with this insulin) injection solution…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, resident interview, staff interview, review of a self-reported incident, review of the facility investigation, review of staff schedules, an employee personnel file and training log, the facility staff failed to report suspected sexual abuse timely. This deficient practice affected one (#46) of three residents reviewed for physical abuse. The facility census was 73. Findings include: Review of Resident #46's medical record revealed an admission date of 10/04/21. Diagnoses included morbid obesity, congestive heart failure, asthma, and diabetes mellitus. Review of Resident #46's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #46 was dependent on staff for bathing/showers, toileting, lower body dressing and personal hygiene. Review of Resident #46's shower/bath record revealed he received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and record review the facility failed to ensure a dependent resident received timely incontinence care. This affected one (Resident #46) with the ability to affect the 48 incontinent residents identified by the facility. The facility census was 73. Findings include: Review of Resident #46's medical record revealed an admission date of 10/04/21. Diagnoses included morbid obesity, congestive heart failure, asthma, and diabetes mellitus. Review of Resident #46's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, was dependent on staff for bathing/showers, toileting, lower body dressing and personal hygiene. Review of Resident #46's care plan updated on 12/27/24 revealed the resident had the risk potential for trauma related to physical/sexual violence. Review of Self-Reported Incident dated 12/26/24 revealed sexual abuse by a facility staff member was reported by the victim, Resident #46 and was being investigated. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel record review, staff interview, and policy review, the facility failed to ensure employed State Tested Nursing Aides (STNA) were properly licensed with the State of Ohio. This had the ability to affect all 77 residents. The facility census was 77. Findings included: Review of STNA #200's personnel file revealed a hire date of [DATE]. The STNA file contained a copy of STNA's Nursing Assistant Registration from the State of [NAME] which expired on [DATE]. A search on the State of Ohio Nurse Aide Registry website revealed STNA #200 had no current nor expired licensure. Review of STNA #200's clock in/out report revealed eight hour shifts were worked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A four hour shift was completed on [DATE]. Interview with the Administrator on [DATE] at 12:55 P.M., verified STNA #200 was hired and caring for residents without being certified with the State of Ohio Nurse Aide Registry and has 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 review of the medical record, staff interview, and review of the facility policy, the facility failed to conduct timely fall reviews for three residents (#5, #70 and #71) and further failed to complete a quarterly fall assessment for a resident identified as a high fall risk (Resident #62). This affected four (#5, #70, #62 and #71) of four residents reviewed for falls. The facility census was 68. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 08/30/24. Diagnoses included dementia, chronic obstructive pulmonary disease, type II diabetes mellitus and metabolic encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment revealed low cognitive function. Resident #70 required the extensive assistance of staff for transfers, toilet hygiene, and mobility. Review of the progress note dated 09/05/24 and timed 5:34 P.M. revealed Resident #70 was observed sitting on the floor with the wheelchair next to him while holding a tissue to the forehead. 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, facility policy review, facility investigation, and staff interviews, the facility failed to report a resident elopement to the state agency as required. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68. Findings include: Review of the medical record for Resident #3 revealed an admission date of 07/31/24, diagnoses included chronic obstructive pulmonary disease, heart disease, hypertension, dementia and type II diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and independently mobile with supervision for mobility required. Review of the hospital history and physical for Resident #3 completed on 07/03/24 and timed 8:35 A.M. revealed Resident #3 was brought to the hospital per emergency services from home due to increase wandering, frequent falls and family concern for safety. According to family, Resident #3 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 interviews, review of the medical record, and review of the facility investigation, the facility failed to ensure a complete and thorough investigation was conducted for a resident elopement. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68. Findings include: Review of the medical record for Resident #3 revealed an admission date of 07/31/24, diagnoses included chronic obstructive pulmonary disease, heart disease, hypertension, dementia and type II diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired, and independently mobile with supervision for mobility required. Review of the hospital history and physical for Resident #3 completed on 07/03/24 and timed 8:35 A.M. revealed Resident #3 was brought to the hospital per emergency services from home due to increase wandering, frequent falls and family concern for safety. According to family…

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 timely assist dependent residents with showers. This affected three of three residents (#8, #57, #22) reviewed for showers. The facility census was 68. Findings included: 1. Review of Resident #8's medical record revealed an admission date of 03/28/24. Diagnoses included dementia, diabetes mellitus, urinary retention, and panic disorder. Review of Resident #8's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed she had low cognitive function. The resident was dependent on staff for showers and toileting. Review of Resident #8's care plan revealed she had a self-care deficit related to dementia. Review of Resident #8's medical record revealed she was scheduled to have showers every Tuesday and Friday on first shift. Review of Resident #8's electronic medical record dated September 2024 revealed the resident received a shower on 09/06/24 and 09/17/24. A bed bath was received on 09/10/24 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 record review, resident interview, staff interview, and policy review, the facility failed to complete weekly skin assessments per physician order. This affected two residents (#8, #57) of three residents reviewed for skin assessments. The facility census was 68. Findings included: 1. Review of Resident #8's medical record revealed an admission date of 03/28/24. Diagnoses included dementia, diabetes mellitus, urinary retention, and panic disorder. Review of Resident #8's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed she had a low cognitive function. The resident was dependent on staff for showers and toileting. Review of Resident #8's care plan revealed she had the potential/actual impairment to skin integrity related to fragile skin and had a self-care deficit. Interventions included the resident required skin inspections to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Review of Resident #8's Weekly Skin Observation Sheets dated August…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, review of facility policy, and review of manufacturer's instruction for use the facility failed to ensure insulin pens were primed prior to administration resulting in a significant medication error. This affected two residents (Resident #42 and #38) of three residents observed for insulin administration. The facility census was 68. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 10/14/22 with diagnoses including dementia, anxiety, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #42 was cognitively intact and received insulin injections. Review of physician orders for Resident #42 revealed an order for insulin Lispro, 100 units per milliliter per sliding scale before meals and at bedtime. The sliding scale included two units of insulin to be administered using a pen injector for a blood sugar of 151 to 200, four units for a blood sugar of 201 to 250,…

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 facility policy, the facility failed to ensure the timely physician notification of laboratory results affecting one Resident (#57) of three residents reviewed for physician laboratory services. The facility census was 68. Findings include: Review of the medical record for Resident #47 revealed an admission date of 02/17/22, diagnoses included major depressive disorder, lymphedema, chronic kidney disease, congestive heart failure, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was cognitively intact, was dependent on staff to meet activities of daily living and was incontinent of bowel and bladder. Review of the physician order dated 08/09/24 revealed a urinalysis with culture and sensitivity to be completed once due to confusion. An additional physician order was placed for a urinalysis with culture and sensitivity on 08/17/24 and included may straight catheterize if needed. Review of the Laboratory…

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 planned menu, the facility failed to ensure vegetables were provided per the planned menu. This affected seven (#15, #16, #17, #18, #19, #20, and #71) of 66 residents who received the noon meal. The facility identified two (#35 and #69) residents received nothing from the kitchen. The facility census was 68. Findings include: Observation during the noon meal service 06/24/24 from approximately 12:00 P.M. until 12:16 P.M. revealed [NAME] #301 plating meals. Interview with [NAME] #301 during the observation confirmed a regular meal would consist of a chicken sandwich with fries and a side of cooked vegetables. Continued observation revealed [NAME] #301 did not have enough vegetables to provide a side of vegetables on the last few meal trays. Interview on 06/24/24 at 12:16 P.M. with [NAME] #301 verified she did not have enough vegetables for the last few meal trays. [NAME] #301 did not provide an explanation regarding why there was not enough vegetable or why she did not prepare more. Observation of meal trays during meal service…

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 policies, the facility failed to ensure fall investigations were completed, and failed to ensure post-fall assessments were completed. This affected two (#12 and #14) of three residents reviewed for falls. The facility census was 68. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/07/19 with diagnoses of dementia and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition, required substantial/maximal assistance for chair to bed transfers and was dependent for toileting hygiene. Further review revealed Resident #12 had no falls since the previous assessment. Review of the Fall Risk Evaluation dated 02/06/24 revealed Resident #12 was at risk for falls. Review of the Incident Log revealed Resident #12 had unwitnessed falls on 06/01/24 and 06/16/24. Review of the facility's incident report for the fall on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure antibiotics were prescribed appropriately to treat Urinary Tract Infections (UTI). This affected one (#12) of two residents reviewed for treatment of UTIs. The facility census was 68. Findings include: Review of the medical record for Resident #12 revealed an admission date of 08/07/19 with diagnoses of dementia and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition, required substantial/maximal assistance for chair to bed transfers and was dependent for toileting hygiene. Review of a progress note dated 06/13/24 revealed Resident #12 was seen by hospice who ordered Bactrim ds (antibiotic) 800 mg for 10 days and to collect urine and send for a urinalysis and culture and sensitivity (UA C&S). Review of a physician order dated 06/14/24 revealed a UA C&S were ordered for Resident #12. Review of a progress note dated 06/15/24 revealed Resident…

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

Based on observation, staff interview, and review of a facility policy, the facility failed to use appropriate hand hygiene while preparing and serving food items. This directly affected all residents with the exception of two (#5 and #43) residents who were identified to receive no food from the kitchen. The facility census was 67. Findings include: 1. Observation on 05/21/24 at 11:28 A.M. at the beginning of meal service revealed [NAME] #195 washed her hands and put on disposable gloves. [NAME] #195 then removed lids from the steam table and put on oven mitts to remove food from the oven. [NAME] #195 removed the oven mitts, picked up a food thermometer, and took the temperature of a pan of enchilada sauce. [NAME] #195 then used a towel to pick the pan of sauce back up, opened the oven door, and placed the pan inside the oven. Continued observation revealed [NAME] #195, wearing the same pair of disposable gloves, sat out meal tickets and beginning to plate food. [NAME] #195 touched the spatula for the enchiladas and the scoops for beans, rice, and enchilada sauce. Continued…

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 previous survey results, medical record review, and staff interview, the facility failed to established an effective Quality Assessment and Assurance committee to identify quality deficiencies and take action to ensure these deficiencies were properly reviewed and acted upon. This had the potential to affect all 67 residents in the facility. The facility census was 67. Findings include: Review of the facility's previous survey results revealed the facility received a deficiency for failing to provide residents with the necessary assistance with activities of daily living (ADLs) during complaint surveys completed on 10/13/22, 02/14/23, 04/14/23, 09/06/23, 02/22/24, and 03/25/24. Review of the medical records for four (#10, #19, #26, and #43) residents during the annual survey conducted 05/20/24 through 05/23/24 revealed the facility failed to provide timely and adequate assistance with ADLs which was confirmed through observation and interviews. During an interview on 05/23/24 at 4:21 P.M., the Administrator verified the facility had received deficiencies for not…

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 Quality Assessment and Assurance (QAA) committee sign-in sheets and staff interview, the facility failed to ensure all required members of the QAA committee attended meetings at least quarterly. This had the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings include: Review of the QAA committee meeting sign-in sheets for 2023 revealed the Medical Director or designee did not attend any meetings for the second quarter between April and June 2023. During an interview on 05/23/24 at 2:19 P.M., the Administrator verified there was no evidence the Medical Director or designee attended any QAA committee meetings in the second quarter between April and June 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and review of the facility policy, the facility failed to maintain a homelike environment for four (#7, #34, #51, and #54) of four residents reviewed for environmental concerns. The facility census was 67. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 11/22/21 with diagnoses of quadriplegia and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition. Observation on 05/20/24 at 8:14 A.M. of Resident #7, who was lying in his bed, revealed a bed rail on the right side of his bed, none on the left, and a crooked headboard. Concurrent interview with Resident #7 revealed he appreciated using the bed rails and wished the right bed rail (against the wall) was replaced. Additionally, he was concerned his headboard was crooked and wished it was fixed. Interview and observation on 05/20/24 at 10:55 A.M. with Licensed Practical Nurse (LPN)…

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 and resident interview, medical record review, and policy review, the facility failed to ensure residents received timely and adequate assistance with activities of daily living tasks. This affected four (#10, #19, #26, and #43) of five residents reviewed for activities of daily living. The facility census was 67. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 10/02/20 with diagnoses of encephalopathy and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required supervision or touching assistance for personal hygiene. Review of the current care plan revealed Resident #10 had an activities of daily living (ADLs) self care performance deficit. Interventions included Resident #10 required extensive assistance with personal hygiene. Further review of the care plan revealed Resident #10 was at risk for impaired skin integrity with an intervention…

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 interview, medical record review, and policy review, the facility failed to ensure resident medications were properly labeled and stored. This affected five (#2, #32, #35, #41, and #52) of 15 residents reviewed for medication storage in a facility census of 67. Findings include: 1. Observation on [DATE] at 11:41 A.M. with Licensed Practical Nurse (LPN) #261, during review of the 500 hall medication storage cart, revealed Resident #35's Lispro insulin pen was dispensed on [DATE] with no date marked when it was opened and Resident #32's Lantus insulin pen was open lacking a open date. In addition Resident #32 had a Lispro insulin opened with no date and a second pen open on [DATE] that expired on [DATE]. Interview with LPN #261 at the time of observation verified insulin pens are to have appropriate date marking when open and verified Resident #35 and Resident #32's insulin was not properly stored 2. Observation on [DATE] at 1:58 P.M. with Registered Nurse (RN) #297, during…

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 menu, spreadsheet, and facility recipe, the facility failed to ensure pureed meals were prepared according to the recipe. This affected four (#25, #42, #44, and #62) of four residents ordered a pureed texture diet. The facility census was 67. Findings include: Review of the menu for the lunch meal on 05/21/24 revealed residents on a regular textured diet received chicken enchiladas, mexican rice, roasted corn, and pudding. Further review revealed residents on a pureed diet would receive pureed enchiladas, pureed rice, pureed lima beans, and pudding. Observation and interview on 05/21/24 at 10:00 A.M. revealed [NAME] #195 preparing pureed food for the lunch meal. [NAME] #195 placed 10 chicken breasts into the food processor and pureed them until smooth. [NAME] #195 added an unmeasured amount of chicken broth to thin the chicken. [NAME] #195 stated four (#25, #42, #44, and #62) residents received pureed diets and some received double portions, so she consistently made extra portions of pureed foods. Continued observation…

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 interview, medical record review, and review of a facility policy, the facility failed to ensure pureed foods were served at an appropriate texture and failed to ensure residents received diets at an appropriate texture to meet their needs. This affected four (#25, #42, #44, and #62) of four residents ordered a a pureed texture diet and one (#11) of two residents reviewed for nutrition. The facility census was 67. Findings include: 1. Observation and interview on 05/21/24 at 10:00 A.M. revealed [NAME] #195 was preparing pureed food for the lunch meal. [NAME] #195 placed 10 chicken breasts into the food processor and pureed them until smooth. [NAME] #195 added an unmeasured amount of chicken broth to thin the chicken. [NAME] #195 stated four (#25, #42, #44, and #62) residents received pureed diets and some received double portions, so she consistently made extra portions of pureed foods. Observation during meal service on 05/21/24, beginning at 11:35 A.M. revealed [NAME]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure infection control procedures were followed regarding enhanced barrier precautions (EBP) and failed to ensure urinary catheter drainage bags were maintained in a manor to prevent infection. This affected eight (#7, #11, #16, #25, #56, #65, #171, and #220) of eight residents reviewed for infection control. The facility census was 67. Findings include: 1. Review of the medical record for Resident #7 revealed an initial admission date of 11/22/21 with diagnoses including dysphagia, hypertension, and hyperlipidemia. Review of physician orders revealed Resident #7 had an order in place dated 01/09/24 for an indwelling (Foley) catheter. The resident also had a physician order initiated for EBP during the survey on 05/20/24 with a start date of 05/21/24. The resident had no previous orders for EBP. Review of the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of resident fund account documentation, and staff interview, the facility failed to provide notification of a spend down when residents reached $200.00 less than their maximum Supplemental Security Income (SSI) benefit. This affected three (#18, #13, and #28) of five residents reviewed for resident funds in a facility census of 67. Findings include: 1. According to the medical record, Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's current fund account balance as of 05/23/24 was $3,590.32 and exceeded the total SSI limit by $1,790.32. Further review revealed no documentation contained in the medical record indicated Resident #18 received a notice when reaching $200.00 less than the benefit limit. 2. According to the medical record, Resident #13 was admitted to the facility on [DATE]. Review of Resident #13's current fund account balance as of 05/23/24 was $2,399.27 and exceeded the total SSI limit by $599.27. Further review revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two (#7 and #56) of three residents reviewed for urinary catheters. The facility census was 67. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 11/22/21 with a diagnosis of neuromuscular dysfunction of the bladder. Review of a physician order dated 01/09/24 revealed Resident #7 had an indwelling urinary (Foley) catheter. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had intact cognition and did not have an indwelling urinary catheter. Observation on 05/21/24 at 7:52 A.M. revealed Resident #7 was sleeping in bed with a covered Foley catheter hanging from the bed frame. Interview on 05/23/24 at approximately 4:30 P.M. with Licensed Practical Nurse (LPN) #372 confirmed Resident #7 had a urinary catheter and confirmed the MDS assessment dated [DATE] indicated Resident #7 did not have a urinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to provide resident-centered activity opportunities. This affected one (#35) of 24 residents reviewed for the provision of activities in a facility census of 67. Findings include: Review of Resident #35's medical record revealed an admission date to the facility on [DATE] with the diagnoses including dementia with mood disturbance, generalized anxiety disorder, type two diabetes mellitus, chronic obstructive pulmonary disease, panic disorder, retention of urine, major depressive disorder, peripheral vascular disease, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #35 with severe cognitive impairment, no behaviors exhibited, required partial to moderate assistance with activities of daily living, was incontinent of bowel and bladder, received a therapeutic diet, had no risk for pressure ulcer development, and received antianxiety, antidepressant, antiplatelet 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 medical record review, observation, resident interview, and staff interview, the facility failed to ensure ancillary services were provided to residents with hearing impairments. This affected one (#170) of one residents reviewed for hearing. The facility census was 67. Findings include: Review of the medical record identified Resident #170 was admitted to the facility on [DATE]. Diagnoses included heart failure, hypertension, hyperlipidemia, and depression. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #170 was cognitively intact and was dependent on staff assistance for a majority of the activities of daily living. Resident #170 did not use hearing aids. Review of the social service progress notes dated 12/22/22 identified Resident #170 was seen by audiology who reported a physician consult for wax removal and for a medical consult to obtain medical clearance for hearing aids. Review of the hearing instrument medical clearance form dated 12/22/22 identified…

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 review of the facility wound treatment policy, the facility failed to ensure resident pressure ulcer treatments were applied in accordance with physician orders. This affected two (#25 and #65) of two sampled residents reviewed for pressure ulcer treatment in a facility census of 67. Findings include: 1. Review of the medical record revealed Resident #25 admitted to the facility on [DATE] with the diagnoses including osteomyelitis of the right ankle and foot, cerebral infarction, chronic embolism and thrombosis of the deep veins in the lower extremity, chronic hepatitis, hypertension, encephalopathy, and osteoarthritis. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #25 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, received nutrition via tube feeding, and was on a mechanically altered…

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 residents received sufficient services to promote incontinence needs were provided suprapubic catheter care and maintenance as needed. This affected two (#11 and #65) of five sampled residents reviewed for incontinence and urinary bladder needs in a facility census of 67. Findings include: 1. Review of Resident #11's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, coronary artery disease, paranoid schizophrenia, neuromuscular dysfunction of bladder, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, supra-pubic urinary catheter, history of urinary tract infection, bipolar disorder, anxiety disorder, hypertension, and anemia. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #11 with intact cognition, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure nutrition assessments were completed upon admission and quarterly. This affected one (#22) of two residents reviewed for nutrition. The facility census was 67. Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/30/23 with diagnoses of chronic kidney disease, type two diabetes mellitus, delusional disorders, hyperlipidemia, and a body mass index indicating the resident was overweight. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the current care plan revealed Resident #22 was at risk for malnutrition related to a diagnoses of chronic kidney disease, diabetes mellitus, and bipolar disorder. Interventions included to update food preferences and provide supplement as ordered. Review of the weight history for Resident #22 revealed non-significant weight gain of five pounds over…

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, personnel file review, and memory care unit criteria documentation review, the facility failed to ensure residents with diagnosis of dementia received appropriate care and services and staff working with those resident were provided sufficient education to ensure those care and services needs were met to ensure the residents maintained their highest practicable physical, mental, and psychosocial well-being. This affected one (#35) of one residents reviewed for dementia related behavioral services in a facility census of 67. Findings include: Review of the medical record revealed Resident #35 admitted to the facility on [DATE] with the diagnoses including dementia with mood disturbance, generalized anxiety disorder, type two diabetes mellitus, chronic obstructive pulmonary disease, panic disorder, retention of urine, major depressive disorder, peripheral vascular disease, and hypertension. Review of the most current 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 review of the pharmacy recommendations, review of the medical record, and staff interview, the facility failed to ensure laboratory tests were completed per pharmacist recommendations or physician orders. This affected three (#7, #10, and #35) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 11/22/21 with diagnoses of quadriplegia, type two diabetes mellitus, depression, and venous thrombosis (blood clots). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition. Review of a pharmacy recommendation dated 03/28/24 revealed Resident #7 should have laboratory tests drawn for a basic metabolic panel (BMP), complete blood count (CBC), and Hemoglobin A1C upon receipt of the recommendation and every six months. Review of a physician order dated 04/24/24 revealed Resident #7 should have laboratory tests drawn for Hemoglobin…

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 provide ongoing rehabilitation services or restorative services to address range of motion and contracture prevention. This affected one (#43) of one residents reviewed for rehabilitation and range of motion in a facility census of 67. Findings include: Review of the medical record revealed Resident #43 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertension, aphasia, urinary retention, dysphagia, cerebral atherosclerosis, delirium, and major depressive disorder. Review of the most current Minimum Data Set assessment dated [DATE] revealed Resident #43 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living, had no behaviors or mood disturbance, was always incontinent, received nutrition via feeding tube, and received speech, physical, and occupational…

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 interviews, and review of a facility policy, the facility failed to ensure each resident's electronic medical record was complete and accurate. This affected two (#19 and #220) of 19 resident records reviewed. The facility census was 67. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 10/15/20 with diagnoses of type two diabetes mellitus and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had intact cognition and had no wounds at the time of the assessment. Review of a wound care service provider note dated 04/30/24 revealed Resident #19 had a skin tear on the left foot, second toe. Review of a provider note dated 05/07/24 revealed the skin tear on the left foot, second toe was scabbed. Further review of the provider notes from 05/14/24 and 05/21/24 revealed the wound on the left foot, second toe continued to be monitored by…

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, hospice staff interview, and review of the facility policy, the facility failed to ensure communication and coordination of care occurred between the facility and the hospice provider. This affected one (#65) of one residents reviewed for hospice care. The facility census was 67. Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/20/24 with diagnoses of severe protein-calorie malnutrition, anxiety, and depression. Further review revealed Resident #65 was admitted under the care of hospice. Review of the admission Minimum Data Set (MDS) assessment completed 02/27/24 revealed Resident #65 had intact cognition. Resident #65 was not at risk for developing pressure injuries, no pressure injury was present on admission, and a pressure reducing mattress was in place. Review of the quarterly Braden Scale for predicting pressure sore risk assessment dated [DATE] revealed Resident #65 was at risk for developing pressure…

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, staff interviews, review of product information, and review of the facility policy, the facility failed to ensure food was cooked to the proper temperature before serving to residents. This affected all residents in the facility except 14 residents identified by the facility who did not consume the fish ( #13, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30). The facility census was 68. Findings include: Observation of meal service on 04/15/24 at 11:24 A.M. with Dietary Manager (DM) #300 revealed she prepared baked fish sticks for the noon meal. DM #300 checked the temperature of the fish sticks and determined they were 151 degrees Fahrenheit (F). Interview on 04/15/24 at 11:32 A.M. with DM #300 revealed the fish sticks should be 160 degrees F and confirmed they only reached 151 degrees F. DM #300 progressed with meal service and did not reheat the fish sticks. Observation during dining on 04/15/24 between 11:30 A.M. and 12:30 P.M. revealed residents in the dining room consumed fish sticks and voiced no concerns. Interview on 04/15/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents were safely transferred using a mechanical lift. This affected one (#17) of one resident reviewed for transfers. The facility census was 68. Findings include: Review of the medical record for Resident #17 revealed an admission date of 03/18/24 with diagnoses of hemiplegia and hemiparesis and history of stroke. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition and was dependent on staff for bed-to-chair transfers. Review of the current physician orders for Resident #17 revealed no orders for using a mechanical lift to transfer Resident #17. Review of the current care plan revealed Resident #17 was totally dependent on one to two people for transfers. The care plan did not indicate how Resident #17 should be transferred. Observation on 04/11/24 at 1:31 P.M. revealed Resident #17 sitting in a recliner chair 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 medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure the residents received timely incontinence care. This affected two (#13 and #14) of three residents observed for incontinence care. The facility census was 68. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 07/13/22. Diagnoses included chronic obstruction pulmonary disease, chronic kidney disease, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively impaired and was dependent on staff for toilet hygiene and bathing and was incontinent of bowel and bladder. Review of the care plan for Resident #13 revealed the resident had an activities of daily living performance deficit related to impaired balance, shortness of breath secondary to chronic obstructive pulmonary disease. Interventions included one staff assistant for bathing and toilet use, 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.

Based on record review, staff and pharmacist interview, observation, review of the manufacturer instructions, and review of the facility policy, the facility failed to procure an insulin pen needle to properly administer insulin via an insulin pen to the resident according to manufacturer instructions. This affected two (#15 and #16) of two residents reviewed for insulin administration. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 10/14/22. Diagnosis included type II diabetes mellitus. Review of the physician order dated 02/22/24 revealed Resident #16 was to receive 45 units of insulin glargine (100 units per milliliter) subcutaneously once a day. Observation on 04/11/24 from 9:23 A.M. to 9:37 A.M. of medication administration for Resident #16 revealed Licensed Practical Nurse (LPN) #502 removed an unopened glargine insulin pen from the medication refrigerator. LPN #502 dialed the insulin pen to 45, cleansed the tip of insulin pen with alcohol, picked up the insulin syringe from the top of the medication cart, picked up the insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and review of Resident Council meeting minutes, the facility failed to ensure resident call lights were answered in a timely manner. This affected one (Resident #05) of one resident reviewed for call lights. The facility census was 67. Findings include: Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, asthma, weakness, and hypertension. Review of Resident #05's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was assessed as cognitively intact and dependent on staff assistance for showering/bathing and personal hygiene. No behaviors were noted within the assessment. Observation on 03/25/24 from 10:29 A.M. to 10:58 A.M. revealed Resident #05's call light had been activated for at least 29 minutes. At 10:58 A.M., State Tested Nurse Aide (STNA) #156 entered Resident #05's room and stated they would retrieve supplies to assist Resident #05 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 record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received assistance with bathing as scheduled. This affected one (Resident #05) of three residents reviewed for activities of daily living. The facility census was 67. Findings include: Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, asthma, weakness, and hypertension. Review of Resident #05's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was assessed as cognitively intact and dependent on staff assistance for showering/bathing and personal hygiene. No behaviors were noted within the assessment. Review of Resident #05's plan of care revised 08/23/23, revealed the resident had an activities of daily living self-care performance deficit related to activity intolerance, fatigue, limited mobility, shortness of breath, and weakness. Interventions included the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure corridor floor tile was maintained free of damage, debris, heavy stains and extensive tracking. This affected 62 residents residing in the north and south nursing units, excluding three residents (#20, #21, #22) residing in the dementia unit. Facility census 65. Findings include: On 02/21/24 at 5:45 A.M. observation of facility floor conditions were as follows; 1. The north hall between administrator office and north nurses station discovered heavily worn floor tiles with wax residue removed from surface and wax build-up residue in doorway thresholds. Floor tiles were identified with black stains and scattered paper debris, including two extinguished cigarettes. Interview with State Tested Nurse Aide (STNA) #300 at 5:50 A.M. verified and stated a resident had discarded them after coming inside from smoking. 2. The north halls between the nurses station and exit door near room [ROOM NUMBER] Flooring and flooring tiles from the cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure residents received baths and/or showers as scheduled. This affected two (Residents #3 and #19) of five sampled residents reviewed activities of daily living. The census was 65. Findings include: 1. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including, generalized arthritis, chronic obstructive pulmonary disease, cerebral infarction, hemiplegia affecting right side, morbid obesity, anxiety disorder, major depression, bipolar disorder, and fibromyalgia. Review of the Minimum Data Set (MDS) assessment, dated 12/05/23, documented Resident #3 was cognitively intact. Resident #3 required supervision or touching assist with activities of daily living and was incontinent of bowel and bladder. Review of the plan of care dated 04/12/23 revealed Resident #3 had an activity of daily living (ADL) self-care performance deficit related to disease process, and additional ADL assistance 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.

Based on observation, staff interview, and review of a kitchen cleaning schedule, the facility failed to maintain the kitchen in a clean and sanitary manner. This had the potential to affect all 57 residents identified by the facility as receiving food from the kitchen. The facility census was 57. Findings include: Observation on 09/05/23 at 8:30 A.M. of the kitchen revealed a black substance on the ceiling over the dishwasher, on the walls to the left and right of the dishwasher, and on the wall over the single sink in the dish room. Observation and interview on 09/05/23 at 8:40 A.M. with Dietary Manager (DM) #110 confirmed the black substance on the walls and the ceiling in the kitchen dish room and stated she believed it to be mildew. DM #110 explained the exhaust system over the dishwasher did not work, resulting in moisture being contained in the areas. While dietary staff turned on the exhaust system in the main kitchen area, DM #110 stated it was not helpful in the dish room. DM #110 stated the facility had someone come out and clean the dish room walls and ceiling a couple…

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 interview, review of pest control services reports, and review of a facility policy, the facility failed to maintain an effective pest control program. This had the potential to affect all 57 residents of the facility. The facility census was 57. Findings include: Observation on 09/05/23 at 8:30 A.M. of the kitchen revealed several gnats flying around the kitchen. Observation and interview on 09/05/23 at 8:40 A.M. with Dietary Manager (DM) #110 verified the gnats in the kitchen and stated she did not know why the facility could not get rid of them. Random observations on 09/05/23 from 8:45 A.M. through 8:50 A.M. revealed gnats in the facility hallways, bathrooms, and resident rooms. Interview on 09/05/23 at 8:51 A.M. with Unit Manager (UM) #155 verified the gnats in the facility. UM #155 stated they kept coming up with different ways to catch them, but it was not working. UM #155 stated the gnats were all over, not just at the facility, but all over. Interview and observation on 09/05/23 at 9:14 A.M. with Resident #56 revealed the resident…

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

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure residents utilized non-combustible containers to extinguish smoking materials. This had the potential to affect 18 (#1, #4, #6, #7, #11, #15, #16, #20, #26, #29, #30, #35, #36, #38, #42, #48, #55, and #56) residents identified by the facility as residents who smoke. The facility census was 57. Findings include: Observation on 09/05/23 at 10:44 A.M., revealed the designated resident smoking area was located on a covered patio in a courtyard area outside the dining room. Further observation of the smoking area revealed two uncovered metal buckets, two plastic flower pots, and a small plastic garbage can containing cigarette butts. Continued observation revealed Resident #7 dropped a lit cigarette butt onto the ground. Additionally, nine cigarette butts were observed laying under the bushes next to the smoking patio. Observation and interview on 09/05/23 at 2:47 P.M., with the Administrator verified the cigarette butts laying around the bushes on the smoking patio, and verified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview and staff interview, and review of facility policy, the facility failed to ensure residents were provided assistance with nail care and shaving. This affected one (#14) of three residents reviewed for activities of daily living. The facility census was 57. Findings include: Review of Resident #14's medical record revealed an admission date of 02/13/23. Diagnoses included anemia, moderate protein-calorie malnutrition, alcoholic cirrhosis of liver with ascites, atrial fibrillation, viral hepatitis B, benign prostatic hyperplasia, hypertension, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was severely cognitively impaired and required extensive assistance with dressing, toilet use, and personal hygiene. Additionally, Resident #14 had no refusals of care. Review of a plan of care focus area, revised on 02/21/23, revealed Resident #14 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.

Based on observation, staff interview, review of a facility staff roster, review of employee testing logs and forms, review of an employee COVID-19 vaccination status log, review of an employee COVID-19 positivity rates tracking log, review of employee and resident COVID-19 positive test log, review of the Centers for Disease Control and Prevention (CDC) website, and review of a facility COVID-19 policy, the facility failed to ensure employees unvaccinated against COVID-19 were tested for COVID-19 infection at appropriate intervals. This had potential to affect all 83 residents residing in the facility. The census was 83. Findings include: Review of an employee COVID-19 vaccination status log present to the survey team on 10/18/21 revealed a total of 39 facility staff refused the COVID-19 vaccination including Licensed Practical Nurse (LPN) #401 and State Tested Nurses Aide (STNA) #414. Further review revealed STNA #431 received a single dose of Pzifer COVID-19 vaccine on 10/15/21. Review of a staff roster revealed LPN #401 was hired on 06/11/21, STNA #414 was hired on 05/29/20, 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 and resident interview, pest control logs, and policy review the facility failed to ensure proper pest control when flies were in the facility. This had the potential to affect all 83 residents who reside in the facility. The facility census was 83. Findings include: Observation on 10/18/21 at 12:30 P.M. in Resident #57's room revealed a fly. Observation on 10/18/21 at 3:14 P.M. of Resident #35 found a fly flying around the room and landing on Resident #35's bedside table. Interview on 10/18/21 at 3:16 P.M. with Resident #35 revealed the flies in the facility were a horrible issue. Resident #35 reported she slept with her mouth open due to breathing issues. Resident #35 reported a few days ago she was awoken by a fly landing on her tongue. Observation on 10/19/21 at 1:50 P.M. revealed two flies at the nurse's station in the 100 and 200 hall. Observation on 10/19/21 at 2:00 P.M. in Resident #23 revealed two flies in the resident room with one fly on the resident. Interview on 10/19/21 at 2:04 P.M. with Licensed Practical Nurse (LPN) #527 verified the flies…

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 resident council minutes and staff and resident interview the facility failed to ensure resident concerns were resolved and/or documented in the resident council meeting minutes. This affected four residents (#19, #22, #53, and #67) who regularly attended the resident council meetings. The facility census was 83. Findings include: Review of Resident Council meeting minutes dated 10/05/21, 08/03/21, 07/20/21, 07/06/21, 03/12/21 and 02/05/21 revealed no documentation on follow-up from the previous month's meeting. Interview with four residents (#19, #22, #53, and #67) on 10/20/21 at 11:45 A.M. revealed had not felt their concerns were addressed by the facility and they rarely talked about the previous month's concerns or resolutions at the monthly meeting. Interview on 10/20/21 at 12:50 P.M., the Recreation Director #519 verified resident concerns from the previous month's meetings were briefly discussed but were not documented on a regular basis. She further stated there was no policy regarding resident council.

Based on review of the resident council minutes and staff and resident interview the facility failed to ensure resident rights were discussed in monthly resident council meeting. This affected four residents (#19, #22, #53, and #67) who regularly attended the resident council meetings. The facility census was 83. Findings include: Review of Resident Council meeting minutes dated 02/05/21,03/12/21, 04/6/21, 05/11/21, 06/04/21, 07/06/21, 07/20/21. 08/03/21, 09/07/21, 10/05/21 revealed no documentation on discussion of resident rights. Interview on 10/20/21 at 11:45 A.M., with Resident #19, #22, #53, and #67 revealed resident rights were not discussed during resident council meetings. Interview on 10/20/21 at 12:50 P.M., with Recreation Director #519 verified resident rights were not formally and regularly discussed during resident council meetings. She further verified there was no policy concerning resident rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnosis included peripheral vascular disease, anemia, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 10/13/21, revealed the resident was cognitively intact. Review of the Smoking Safety Screen dated 05/24/21 revealed Resident #19 was approved to smoke unsupervised and the facility was store the lighter and cigarettes. Interview on 10/18/21 at 4:07 P.M., with Resident #19 reported she had her cigarettes in her possession and presented them. Resident #19 reported she does not have a lighter however any resident's outside would light it for her. Interview on 10/20/21 at 9:43 A.M., with Resident #19 reported the facility was now making her lock up the cigarettes at the nurses station. 4. Medical record review of Resident #43 revealed an admission date of 08/18/21. Diagnosis included multiple fractures of ribs right side subsequent encounter for fracture 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.

Based on observation, staff interview, and policy review the facility failed to ensure a clean and sanitary kitchen and sanitary meal distribution. This had the potential to affect 82 residents of 83 residents who receive nutrition from the kitchen. The facility identified one Resident (#7) who received no oral intake. The facility census was 83. Findings include: 1. Observation on 10/18/21 at 8:45 A.M. of the facility kitchen revealed the ice machine contained a layer of black colored debris, which appeared to be mold, across the inside top of the ice machine and on the outside of the ice machine where the lid opens. Additional observation on 10/18/21 at 8:50 A.M. of the walk-in freezer revealed approximately three feet by three feet wide and up to six inches in depth of ice accumulated on the floor in addition to ice covered cardboard boxes and plastic bags of food. Interview on 10/18/21 at 9:02 A.M., with Dietary Manager #415 verified the mold like substance in the ice machine and ice build up in the walk-in freezer. Dietary Manager #415 reported the ice machine cleaning was not…

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 and staff interview, and policy review the facility failed to ensure proper infection control for resident's respiratory devices and urinary catheter. This affected two residents (#23 and #283) of two residents. The census was 83. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/23/21. Diagnosis included moderate intellectual disabilities, gastro-esophageal reflux disease without esophagitis, supraventricular tachycardia, palpitations, hypomagnesemia, essential (primary) hypertension, hyperlipidemia, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, personal history of other mental and behavioral disorders, tobacco use, acute cystitis without hematuria, hyperkalemia, type two diabetes mellitus with diabetic polyneuropathy, hypoxemia, cardiomyopathy, undifferentiated schizophrenia, and major depressive disorder recurrent. Review of the MDS assessment, dated 10/15/21, revealed the resident was cognitively intact and was ordered oxygen. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and policy review the facility failed to ensure dependent resident's call lights and resident rooms were adapted for independence. This affected two residents (#46 and #283) of three reviewed for accommodation of needs. The facility census was 83. Findings Include: 1. Review of Resident #46's medical record revealed an admission date of 01/05/21. Diagnoses included cerebral infarction, cortical blindness, major depressive disorder, and communication deficit. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of 13 indicating Resident #46 was cognitively intact. Resident #46 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #46 displayed no behaviors during the review period. Review of the care plan revised 03/16/21 revealed Resident #46 required supports and interventions for dependence on staff for meeting needs, impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to ensure a comprehensive resident assessment was completed after a change in condition. This affected one resident (#49) of 19 residents reviewed for potential change in condition. The facility census was 83. Findings Include: Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE]. Diagnoses include deep vein thrombosis (blood clot) to the left lower extremity, hypertension, diabetes mellitus type II, protein calorie malnutrition, acute kidney failure, dehydration, hypotension, heart failure, depression, dementia, and muscle wasting. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had no cognitive issues, abnormal behaviors or rejection of care. There was no terminal prognosis or issues with chewing, however the resident was on a mechanically altered and therapeutic diet. Review of physician orders dated 09/30/21 revealed the 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.

Based on medical record review, staff interview and policy review the facility failed to implement a baseline care plan for a resident who had pressure ulcers on admission. This affected one resident (#283) of 19 residents reviewed for care plans. The facility census was 83. Findings include: Review of the medical record for Resident #283 revealed an admission date of 10/01/21. Diagnoses included multiple sclerosis, repeated falls, neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) revealed it was not yet completed. Review of the baseline care plan revealed there was no plan related to pressure ulcers. Review of the admission nursing assessment for skin dated 10/02/21 revealed Resident #283 had a right buttock partial thickness wound which measured 4.2 centimeter (cm) by 3.8 cm by less than 0.1 cm. Left buttock partial thickness 2.4 cm by 1.4 cm by less than 0.1 cm and a treatment was recommended. Review of the physician orders dated 10/02/21 revealed Resident #283 had an order to cleanse the excoriating area to both buttocks with normal saline and cover 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 record review, resident and staff interview and policy review the facility failed to invite and offer quarterly care plan conferences. This affected two residents (#19 and #23) of two residents reviewed for comprehensive care plan conferences. The facility census was 83. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/23/21. Diagnosis included moderate intellectual disabilities, gastro-esophageal reflux disease without esophagitis, supraventricular tachycardia palpitations, hypomagnesemia, essential (primary) hypertension, hyperlipidemia, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, personal history of other mental and behavioral disorders, tobacco use, syncope and collapse, acute cystitis without hematuria, hyperkalemia, retention of urine, type two diabetes mellitus with diabetic polyneuropathy, type two diabetes mellitus with hyperglycemia, hypoxemia, cardiomyopathy, benign prostatic hyperplasia without…

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 policy review the facility failed to ensure resident blood sugars were monitored according to physician orders. This affected one resident (#36) of one reviewed for blood sugar monitoring of seven residents reviewed for unnecessary medications. The facility census was 83. Findings Include: Review of of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, anxiety disorder, muscle wasting, cognitive communication deficit, and anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #36 was cognitively intact. Resident #36 required limited assistance with transfer and extensive assistance with dressing, toilet use, and personal hygiene. Resident #36 displayed no behaviors during the review period. Review of the physician orders dated 08/12/21 revealed Resident #36 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 medical record review, observation, and resident and staff interview the facility failed to ensure residents had adequate fluids, of the appropriately ordered texture, available for consumption. This affected one resident (#129) of two residents reviewed for hydration. The facility census was 83. Findings include: Review of Resident #129's medical record revealed and admission date of 10/16/21. Diagnoses included schizoaffective disorder, unspecified convulsions, altered mental status, and acute cystitis without hematuria. Review of an admission nursing assessment dated [DATE] revealed Resident #129 was alert and oriented to person and place and was independent with eating. Review of a physician order dated 10/18/21 revealed Resident #129 was ordered a pureed diet, pureed texture, with nectar consistency. Observation on 10/18/21 at 10:12 A.M. revealed Resident #129 laying in bed with no pitcher or cup of fluids for consumption noted in his bed room. Observation on 10/18/21 at 10:53 A.M. 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, observation, resident and staff interview, and policy review the facility failed to ensure medications were received as ordered. This affected two residents (#43 and #55) of 19 reviewed. The facility census was 83. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 08/18/21. Diagnosis included multiple fractures of ribs right side subsequent encounter for fracture with routine healing, repeated falls, end stage renal disease, dependence on renal dialysis, hypothyroidism, hyperlipidemia, essential (primary) hypertension, anemia in chronic kidney disease, hypotension, varicose veins of bilateral lower extremities, anxiety disorder, major depressive disorder recurrent severe without psychotic features, paroxysmal atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Observation on 10/20/21 at 4:10 P.M. revealed a medication cup with four pills on 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.