Franciscan Care Ctr Sylvania

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure treatments were completed by a licensed nurse. This affected one (#20) of four residents reviewed for administration of treatments. The facility census was 71.Findings include:Review of the Medical Record for Resident #20 revealed an admission on [DATE]. Diagnoses included cerebral palsy, osteoarthritis, and morbid obesity.Review of the Minimum Data Set (MDS) dated revealed Resident #20 was cognitively intact. Resident #20 was dependent on staff for transfers using a mechanical lift.Review of the care plan dated 06/25/25 revealed Resident #20 had a break in skin integrity. Interventions included treatments as ordered, and weekly skin checks. Further review of the care plan revealed Resident #20 was at risk for skin breakdown. Interventions included clean and dry skin after each incontinent episode and treatments as ordered. Additional review of the care plan revealed Resident #20 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and facility staff interview the facility failed to ensure residents received meals to meet the resident's nutrition needs. This affected one (Resident #55) of three reviewed for feeding assistance The facility census was 71.Findings include:Review of the medical record for Resident #55 revealed an admission on [DATE]. Diagnoses included Type II Diabetes Mellitus, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of eight. Resident #55 was assessed to require assistance with meals and was dependent on staff for Activities of Daily Living (ADL) care.Review of the care plan dated 06/20/24 revealed Resident #55 had ADL self-care performance deficit related to impaired vision, and arthritis. Staff were to help Resident #55 eat and encourage to feed self if possible. Resident #55 was blind and…

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

Based on staff interviews, review of facility investigation, review of a police report, review of the facilities Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to report an allegation of neglect by a nurse to the State Survey Agency, Ohio Department of Health. This had the potential to affect 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) in which the nurse was responsible for the night of the allegation of neglect. The facility census was 64.Findings include: Review of the facility provided timeline for 12/12/25 revealed Licensed Practical Nurse (LPN) #200 punched in for work on 12/12/25 at 10:20 P.M. and received report from the off-going LPN, LPN #152, at approximately 11:00 P.M. At approximately 11:12 P.M. on 12/12/25 LPN #152 and Certified Nursing Assistant (CNA) #144 drove LPN #200 to the gas station and he did not return to the facility until 11:27 P.M. on 12/12/25. Review of the police report revealed on 12/12/25, a resident of the nursing home called emergency 9-1-1 and reported her nurse 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 staff interviews, review of the police report, review of facility policy, and review of the facility's investigation, the facility failed to complete and thorough investigation of possible resident neglect by a nurse. This had the potential to affect 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) which the nurse was responsible for the night of the allegation of neglect. The facility census was 64.Findings include: Review of the police report revealed on 12/12/25, a resident of the nursing home called emergency 9-1-1 and reported her nurse was intoxicated and smelled like alcohol. Upon police arrival, Licensed Practical Nurse (LPN) #200 had glossy eyes, slurred and abnormal speech. Due to LPN #200's impairment, policy began an investigation to determine if resident neglect had occurred, was occurring, or was going to occur. LPN #200 was walking around the facility speaking in a loud voice and using vulgar language in front of residents. On 12/13/25 at 12:45 A.M., LPN #200 was arrested for disorderly conduct: public intoxication; offensive…

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 and staff interview, and facility policy review, the facility failed to ensure dependent residents received timely bathing. This affected two (#515 and #569) of three residents reviewed for showers. The facility census was 70.Findings included:1. Review of Resident #569's medical record revealed an admission date of 05/25/24. Diagnoses included dementia, peripheral vascular disease, chronic obstructive pulmonary disease, and chronic pain syndrome. Review of Resident #569's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required substantial assistance with activities of daily living (ADLs).Review of Resident #569's care plan revealed the resident had an ADLs self-care deficit due to chronic obstructive pulmonary disease, dementia, depression, and obesity. Interventions include staff assistance was required to provide a bath or shower, and a sponge bath was to be completed when a full bath or shower could not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the National Library of Medicine webpage, the facility failed to ensure resident bowel movements were monitored to provide interventions to prevent constipation. This affected two (#523 and #552) of two residents reviewed for constipation. The facility census was 70.Findings included:1. Review of the medical record for Resident #523 revealed she was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), fracture of the sacrum, type two diabetes mellitus, heart disease, osteoarthritis, depression, and anxiety.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #523 revealed was assessed with moderate cognitive impairment, did not refuse care, was always incontinent of bowel and bladder, and was dependent for activities of daily living.Review of the active physician orders as of 11/19/25 for Resident #523 revealed medication orders Colace 100 milligrams (mg) twice daily for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility protocol, the facility failed to ensure staff received a physician's order prior to removing an indwelling urinary catheter. This affected one (#572) of six residents reviewed with urinary catheters. The facility census was 70. Findings included: Review of Resident #572's medical record revealed an admission date of [DATE]. Diagnoses included bacteremia, chronic kidney disease, and neuromuscular dysfunction of the bladder. The resident expired under hospice care on [DATE]. Review of Resident #572's Minimum Data Set assessment dated [DATE] revealed the resident had an intact cognitive function. The resident was always incontinent of bowel and bladder and dependent on staff for all activities of daily living. Review of Resident #572's care plan dated [DATE] revealed she had an indwelling Foley catheter due to a neurogenic bladder. Interventions were to monitor for pain or discomfort due to the catheter. Review of Resident #572's nursing…

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

Based on review of facility documents, staff interviews, and review of facility policy the facility failed to ensure resident concerns and grievances were addressed timely. This had the potential to affect all residents. The facility census was 70. Review of the grievance logs and reports for April 2025 through September 2025 revealed 30 of 75 grievances filed had not been followed up on. Review of the Resident Council meeting minutes for June 2025 revealed resident concerns related to untimely medication administration and undercooked food. The concerns were not addressed or followed up on.Review of the Resident Council meeting minutes for July 2025 revealed resident concerns related to staffing, staff approach, and showers were not addressed or followed up on.Review of the Resident Council meeting minutes for August 2025 revealed a report Licensed Practical Nurse (LPN) #522 had been counseled for being untimely with medication administration.Review of the Resident Council meeting minutes for October 2025 revealed resident concerns related to staffing, medication times, and 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 review of medical records, staff interviews, resident interviews, and review of facility documents, the facility failed to ensure sufficient staffing to provide timely and adequate care to residents. The affected three (#37, #86, and #97) of three residents reviewed for activities of daily living with the potential to affect all residents. The facility census was 70. Review of the medical record for Specified Resident #37 revealed an admission date of 10/02/24, diagnoses included obstructive hypertrophic cardiomyopathy, left bundle branch block, cervical disc degeneration, solitary pulmonary nodule, depression, anxiety, and borderline personality disorder. Review of the Minimum Data Set (MDS) assessment revealed the resident did not refuse care, was occasionally incontinent, required set-up assistance with toileting and personal hygiene, and required supervision assistance with bathing. Review of task sheets for Residents #37 for the month of April 2025 revealed the absence of documentation to support daily living cares had been provided during the hours of 3:00 P.M. 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 observations, resident interviews, staff interviews, and review of facility policy, the facility failed to ensure foul odors were maintained on A, B and C halls. This had the potential to affect all 54 residents on halls A, B, and C. The facility census was 70. Observation on 10/06/25 between 11:45 A.M. and 12:30 P.M. on A, B, and C halls revealed an intermittent foul urine odor throughout each hallway not associated with a resident, resident rooms, or soiled utility room.Observation on 10/07/25 at 11:15 A.M. on A hall revealed an intermittent foul urine odor throughout the hallway and into the adjacent dining room. The odor was not associated with a resident, adjacent resident rooms or soiled utility rooms.Observation on 10/08/25 at 9:10 A.M. at B hall nurse station revealed a foul urine odor in the hallway not associated with a resident, adjacent resident rooms or soiled utility rooms. Observation on 10/14/25 at 2:25 P.M. on A hall revealed an intermittent foul urine odor throughout the hallway and into the adjacent dining room. The odor was not associated with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility self-reported incidents (SRI), staff interviews, and review of the facility policy the facility failed to complete thorough investigations for five of five SRIs reviewed. This affected six (#39, #46, #54, #85, #105, and #108) residents reviewed for facility self-reported incidents. The facility census was 70. Review of the five facility reported self-reported incidents (SRI)'s: 259637 dated 04/23/25, 259639 dated 04/23/25, 259788 dated 04/28/25, 260722 dated 05/22/25, and 262712 dated 07/12/25 revealed thorough investigations were not completed to include any or all of the following: staff interviews and/or statements, resident statements, assessments of like residents, and/or staff education. 1. Review of the medical record for Resident #39 revealed an admission date of 09/20/24 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus, and congestive heart failure (CHF). Review of the quarterly 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 observations, medical record reviews, staff interviews, resident interviews, review of the facility investigation file, review of personnel files, and review of facility policies the facility failed to ensure accurate orders and documentation were in resident medical records. This affected three (Residents #37, #86, and #97) of three residents reviewed for accurate and complete documentation, one (Resident #37) of one resident reviewed for medication administration, and one (Resident #106) of one resident reviewed for treatment administration. The facility census was 70.1.Review of the medical record for Specified Resident #37 revealed an admission date of 10/02/24, diagnoses included obstructive hypertrophic cardiomyopathy, left bundle branch block, cervical disc degeneration, solitary pulmonary nodule, depression, anxiety, and borderline personality disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, did not refuse care, was occasionally…

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 interview, and review of facility policy, the facility failed to ensure meal trays were served in a clean and sanitary manner. This affected eight (#34, #48, #51, #53, #54, #58, #65, and #81) of eight residents observed during meal tray service. The facility census was 70. Observation on 10/06/25 between 12:25 and 12:45 revealed Certified Nurse Assistant (CNA) #525 delivering meal trays to residents. CNA #525 did not perform hand hygiene before she retrieved a meal tray from the cart in the hallway and delivered it to Resident #81's bedside table. CNA #525 touched the bedside table and set up the meal tray for Resident #81; she opened silverware, removed lids from bowls and plates, and inserted a straw into a cup. CNA #525 did not perform hand hygiene before leaving Resident #81's room. CNA #525 returned to the meal tray cart in the hallway, did not perform hand hygiene, and retrieved another meal tray for Resident #51. CNA #525 delivered the meal tray to Resident #51's bedside table. CNA #525 touched the bedside table and did not perform hand hygiene…

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

Based on record review, staff interview, review of the facility Self-Reported Incident (SRI), and review of the facility policy the facility failed to timely report an allegation of abuse. This affected one (#105) of one resident reviewed for timely reporting. The facility census was 70. Review of the medical record revealed Resident #105 had an admission date of 08/21/24 with a diagnosis of dementia. Resident #105 was discharged on 06/23/25. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/04/25, revealed Resident #105 was cognitively impaired. Interview on 10/16/25 at 11:10 A.M. with the Administrator stated on 05/19/25 the Former DON #610 met with Resident #105's daughter and the incident of alleged abuse was reported to Former DON #610. The Administrator further stated she was notified on 05/22/25 of the incident by Former DON #610 and she immediately suspended the alleged perpetrator Former Licensed Practical Nurse (LPN) #601 pending an investigation. Former DON #610 was also suspended pending the investigation for not timely reporting. Further interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of the facility policy, the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one Resident (#77) of one resident reviewed for pre admission screening and resident review (PASRR) assessment. The facility census was 70. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, protein-calorie malnutrition, anxiety, sarcopenia, and epilepsy. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed Resident #77 had intact cognition. Resident #77 had moderately impaired vision and required supervision for mobility and received antipsychotic, antidepressant, and anticonvulsant medications. Review of medical record for Resident #77 revealed a new diagnosis of disorganized schizophrenia in March 2025. In April…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure wound care orders were accurate and completed as ordered. This affected one (#60) of three residents reviewed for wound care. The facility census was 70. Review of the medical record for Resident #60 revealed an admission date of 07/01/25, diagnoses included disruption of wound healing, infection following procedure, dehiscence of amputated stump, gangrene, acidosis, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact, did not refuse care, and required assistance with activities of daily living. Review of physician orders for Resident #60 revealed right leg above the knee amputation (RAKA) wound care order dated 09/09/25 for betadine to be applied to the surgical incision and wrapped with fluff gauze once daily. Review of Resident #60's after visit summary with the vascular surgeon…

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 a resident was seen by a provider during the duration of the admission from 05/07/25 through discharge on [DATE]. This affected one resident (#104) reviewed for physician services. The facility census was 70. Review of the medical record for Former Resident #104 revealed an admission date of 05/07/25 and a discharge date of 08/21/25. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] for Resident #104 revealed she was cognitively intact. Review of the medical record for Resident #104 for physician notes revealed there were no physician progress notes for the resident from admission to discharge. Review of the Facility assessment dated stated residents should expect a standard of care from medical practitioners and other healthcare professionals necessary to provide the level and types of support and care needed. This deficiency represents non-compliance investigated under Complaint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to timely address psychosocial needs and failed to implement individualized interventions in a timely manner to maintain the highest level of mental and psychosocial functioning and well-being. The resident had a history of paranoia, hoarding behaviors, and the resident was identified to have a history of acquiring items from the facility including hazardous chemicals. This affected one (#77) of one resident reviewed for mood/behavior/emotional status. The census was 70.Review of the medical record for Resident #77 revealed an admission date of 08/08/22. Diagnoses included unspecified protein-calorie malnutrition, anxiety, sarcopenia, paranoia, and epilepsy. A diagnosis of schizophrenia with disorganized thoughts was added in April 2025. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, but 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 observation, resident interview, Power of Attorney (POA) interview, staff interview, medical record review, review of the Payroll Based Journal (PBJ) Staffing Report and review of the facility's staffing schedule, the facility failed to ensure adequate staffing to meet resident needs. This affected four (#9, #1, #4 and #10) of 14 residents reviewed for staffing and had the potential to affect all residents in the facility. The facility census was 68. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 03/01/23. Diagnoses included fracture of lower end right humerus subsequent encounter (02/21/25), cerebral infarction, Type II diabetes, dysphagia, osteoarthritis, seizures, bipolar disorder, and anxiety disorder. Review of Resident #9's Minimum Data Set (MDS) assessment, dated 03/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #9 was moderately cognitively impaired. Resident #9 was dependent on staff for toilet use, transfers, and bathing. Resident #9 received a mechanically altered therapeutic…

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 the Payroll-Based Journal (PBJ) Staffing Data Report, staff interview and review of the facility policy, the facility failed to submit required staffing information. This had the potential to affect all 68 residents who resided in the facility. The facility census was 68. Findings include: Review of the PBJ Staffing Data Report for Quarter Four of 2024 (July 1 - September 30) revealed the facility triggered for failure to submit data for the quarter. Interview on 04/03/25 at 11:48 A.M. with the Administrator verified the PBJ data was not submitted for Quarter Four of 2024 (July 1- September 30). The Administrator reported Human Resources (HR) was responsible for submitting the data and it was not done. The Administrator stated she did not know why the data was not submitted as required. The Administrator provided a copy of the updated policy and reported she submitted the data for the quarter including the months of October, November, and December 2024. Review of the facility policy titled, PBJ Protocol, revised 11/19/24, revealed staffing data was to be…

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

Based on observation, medical record review, resident interview, Power of Attorney (POA) interview, staff interview and review of facility policy, the facility failed to ensure dependent residents received feeding assistance and scheduled showers. This affected four (#1, #6, #10, and #9) of 14 residents reviewed for activities of daily living (ADLs). The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was assessed with intact cognition and was dependent on staff for the completion of ADLs. Resident #1 was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown.…

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 discharge instructions were provided at the time of discharge from the facility. This affected one (#3) of five residents reviewed for discharge. The facility census was 68. Findings include: Review of Resident #3's medical record revealed an admission date of 08/16/24. Diagnoses included acute cystitis, Type II diabetes mellitus with foot ulcer, cerebral infarction, dementia, paranoid schizophrenia, hypertension, depression, chronic ischemic heart disease, and non-pressure chronic ulcer to the right heel. Review of the most current Minimum Data Set (MDS) assessment, dated 08/22/24, revealed Resident #3 was assessed with severe cognitive impairment, required partial to moderate assistance with activities of daily living (ADLs), utilized a wheelchair for mobility and was propelled by staff, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. 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.

Based on observation, medical record review, and staff interview, the facility failed to ensure timely repositioning and offloading was provided to dependent residents to assist in the prevention of pressure ulcers. This affected three (#1, #4, #10) of three residents reviewed for pressure ulcers. The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was assessed with intact cognition and was dependent on staff for the completion of activities of daily living (ADLs), including transfer and bed mobility. Resident #1 was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin…

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

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure timely incontinence care was provided. This affected three (#1, #4, and #10) of three residents reviewed for incontinence care. Additionally, the facility failed to ensure sufficient catheter care or physician orders regarding the maintenance of an indwelling urinary catheter for Resident #1. This affected one (#1) of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was cognitively intact, was dependent on staff for the…

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

Based on observation, resident interview, medical record review and staff interview, the facility failed to ensure medications were available for administration per physician order. This affected one (#1) of seven residents reviewed for medication administration. The facility census was 68. Findings include: Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was cognitively intact. Resident #1 was dependent on staff for the completion of activities of daily living (ADLs), was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 12/21/24, revealed Resident #1 had chronic pain related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the pharmacy delivery manifest, the facility failed to ensure medications were obtained and administered as ordered by the prescribing physician, resulting in a significant medication error. This affected one (#7) of seven residents reviewed for medication administration. The facility census was 68. Findings include: Review of Resident #7's medical record revealed an admission date of 12/20/24. Diagnoses included anemia, cirrhosis, hepatic encephalopathy, chronic kidney disease, Type II diabetes mellitus, major depressive disorder, gastrointestinal hemorrhage, chronic viral hepatitis C, facial weakness, and vitamin d deficiency. Review of the Minimum Data Set (MDS) assessment, dated 01/23/25, revealed Resident #7 was cognitively intact, utilized a wheelchair for mobility, required partial to moderate staff assistance with activities of daily living (ADLs), was incontinent of bowel and bladder, had no fall history, no known weight loss, received a…

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

Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure physician ordered meal textures were served to residents. This affected one (#5) of four residents reviewed for meal textures. The facility census was 68. Findings include: Review of Resident #5's medical record revealed an admission date of 05/18/21. Diagnoses included psychosis, chronic obstructive pulmonary diseases (COPD), major depressive disorder, generalized anxiety disorder, hallucinations, morbid obesity, and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 03/02/25, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #5 was dependent on staff for dressing and transfers, required set up assistance for eating and received a mechanically altered therapeutic diet. Review of the care plan, revised 03/04/25, revealed Resident #5 had a self-care deficit, had impaired cognitive function, was at risk for pain, and was at nutrition and hydration risk. Interventions…

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

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure staff applied personal protective equipment (PPE) when providing high contact care to residents on enhanced barrier precautions (EBP). This affected one (#1) of one resident reviewed for EBP. The facility census was 68. Findings include: Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was cognitively intact, was dependent on staff for the completion of activities of daily living (ADLs), was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of a physician order dated 03/18/25 revealed 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 record review, staff interview, and policy review, the facility failed to ensure residents were prepared a safe and orderly discharge. This affected Residents #8 and #9 reviewed for discharge. The facility census was 76. Findings included: 1. Review of Former Resident (FR) #8's medical record revealed an admission date of 12/11/24 and was discharged to home on [DATE]. Diagnoses included left femur fracture, atrial fibrillation, and dementia. Review of FR #8's discharge Minimum Data Set (MDS) dated [DATE] revealed her cognition was intact. The resident required moderate assistance with toileting, shower/bathing, lower body dressing, chair to bed transfers, toilet transfer, and walking up to 50 feet. Review of FR #8's care plan revealed she required assistance with discharge planning for a home goal and to arrange outside services and equipment needs prior to discharge. Review of FR #8's Notice of Medicare Non-Coverage (NOMNC) revealed an end of service date of 12/29/24. The resident denied an appeal and…

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

Based on medical record review, staff interview, review of shower schedules, and review of a facility policy, the facility failed to ensure residents were provided with scheduled bathing. This affected three (#9, #50, and #68) of three residents reviewed for bathing. The facility census was 76. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 01/06/23. Diagnoses include chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, oral dysphagia, stage three chronic kidney disease, generalized muscle weakness, need for assistance with personal care, anorexia, anxiety disorder, dementia, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 07/05/24, revealed Resident #9 was severely cognitively impaired, was dependent for showering and bathing, and required substantial/maximal assistance with personal hygiene. Review of a facility shower schedule revealed Resident #9 was scheduled for showers every Wednesday and Saturday on second shift. Review of Resident #9's shower documentation for 07/10/24…

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 meals were served in a sanitary manner. This affected four residents (#50, #54, #19, #11) and had the potential to affect all residents who were receiving meals from the kitchen. The facility census was 67. Findings include Observation on 06/11/24 at 11:35 A.M., of meal plating revealed [NAME] #446 was wearing gloves and directly touched the hamburger buns, lettuce, and tomatoes then touched the plates, counter, scoop handles, tongs and bag containing hamburger buns. The cook then again directly touched the hamburger buns, lettuce, and tomato with the same gloved hands. [NAME] #446 repeated this process four times while plating meals for four residents (#50, #54, #19, #11). After surveyor intervention, [NAME] #446 changed his gloves but completed no hand washing, then used tongs for the hamburger buns, lettuce, and tomato. Interview on 06/11/14 at 11:35 A.M., [NAME] #446 verified he was touching the serving handles, plates, and counter then touching the food directly with the same gloved hands.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place and chemicals with a precautionary label were secured. This affected two (#23 and #42) of two residents reviewed for accidents. This had the potential to affect three facility-identified independently ambulatory but cognitively impaired residents (#18, #56, and #60) who resided in the building. The facility census was 67 Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 12/06/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction right dominate side, need for assistance with personal care, abnormal posture, vascular dementia, hypertension. hyperlipidemia, major depressive disorder, and right elbow contracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed [NAME] resident was severely cognitively impaired. Further review of the MDS data revealed Resident #23 was dependent…

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 manufacturer instructions, the facility failed to ensure resident medications were properly labeled and expired medications were not available for use past the expiration date. This affected two medication rooms (C-Hall and B-Hall) and one medication cart (C-Hall). The facility census was 67. Findings include: Observation of the C-Hall medication storage room on 06/12/24 at 8:01 A.M. with the Director of Nursing (DON), revealed two expired blister cards of benzonate 100 milligram (mg) capsules. The first blister card contained three benzonate 100 mg capsules and was marked with an expiration date of 03/28/23. The second blister card contained twenty-nine benzonate 100 mg capsules and was marked with an expiration date of 05/12/24. Further observation of the C-Hall medication storage room revealed ipratropium 0.03% nasal solution with an expiration date of 02/28/23. Interview with the DON at the time of observation verified both blister cards of benzonate and the ipratropium 0.03% nasal solution were expired. Observation of the…

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

Based on facility medical record review, observation, resident and staff interview, and facility policy review, the facility failed to ensure residents were treated with dignity/respect when staff failed to cover the drainage bag of an indwelling urinary catheter. This affected one resident (Resident #13) of five residents reviewed for dignity. The facility census was 67. Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease (COPD), need for assistance with personal care, hypertension (HTN), obstructive and reflux uropathy, peripheral vascular disease, atrial fibrillation (a. fib), chronic kidney disease (CKD), major depressive disorder, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/21/24, revealed Resident #13 was cognitively intact, had an indwelling urinary catheter, and was always incontinent of bowel. Observation on 06/11/24 at 7:41 A.M. revealed Resident #13 had an uncovered indwelling catheter drainage bag hanging…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure access to the call light for one dependent resident (Resident #27) reviewed for call lights in reach. The facility census was 67. Findings include: Review of the medical record for Resident #27 revealed an admission date of 03/24/24. Diagnoses included of metabolic encephalopathy, hemiplegia affecting right dominant side, hemiparesis following cerebral infarction affecting right dominant side, schizoaffective disorder, anxiety disorder, and hydrocephalus. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. The resident was dependent for shower/bathing, personal hygiene, and always incontinent of bowel and bladder. Observation on 06/10/24 at 11:47 A.M. revealed Resident #27 was laying in bed on their back with their call light tied to the right bedrail and hanging down from the bedrail toward the floor, inaccessible to 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure the Pre admission Screen and Resident Review (PASARR) forms were completed for a change of condition in mental health diagnosis. This affected one(#34) of two residents reviewed for PASARR compliance. The facility census was 67. Findings include: Review of Resident #34's medical record revealed an admission date of 10/15/20. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. Resident #34's schizoaffective disorder diagnosis was added 07/07/23. Review of the Minimum Data Set (MDS) assessment, dated 03/19/24, revealed Resident #34 was cognitively intact. Resident #34 was taking a scheduled antipsychotic at the time of the review. Resident #34 displayed no behaviors during the review period. Review of Resident #34's care plan, revised 03/21/24, revealed supports and interventions for impaired cognitive function,…

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 the medical record, staff interview, and policy review, the facility failed to include the use of a psychotropic medication for depression in the resident's comprehensive care plan. This affected one (#67) of three residents reviewed for care planning. The facility census was 67. Findings include Review of the medical record for Resident #67 revealed an admission date of 05/15/24. Diagnoses included systolic depressive disorder and anxiety. Review of a physician order dated 05/16/24 revealed the resident had an order for Zoloft 100 milligrams (mg) daily for depression. Review of the care plan for Resident #67 revealed there was no care plan in place for the use of a psychotropic medication for depression. Interview on 06/11/24 at 8:02 A.M., Registered Nurse (RN) #495 verified there was no plan of care in place for Resident #67's use of the psychotropic medication Zoloft for depression. Review of the policy titled Comprehensive Care Plans, dated 10/24/22, revealed the comprehensive care plan would include measurable objectives and timeframes to meet the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were included in the development for their plan of care and failed to have care planning meetings to periodically review the care plan. This affected two (#39 and #67) of three residents reviewed for care planning. The facility census was 67. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 02/09/23. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 04/17/24, revealed Resident #39 was cognitively intact. Resident #39 required set up assistance with eating and was dependent on staff for toilet use, bathing and dressing. Resident #39 displayed no behaviors during the review period. Review of Resident #39's current care plan, revised 01/29/24, revealed supports and interventions for self-care deficit,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were provided with scheduled grooming and bathing. This affected three (#7, #23, and #273) of seventeen residents observed for activities of daily living. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following subarachnoid hemorrhage, cirrhosis of liver, anxiety disorder, major depression, peripheral vascular disease, anemia, and non-pressure chronic ulcer to right and left foot. Review of the Minimum Data Set assessment, dated 04/25/24, revealed Resident #7 had intact cognition. Resident #7 required assistance with activities of daily living, was incontinent of urine and continent of bowel. Review of the plan of care revealed on 06/26/23 the care plan was revised to address Resident #7's activity of daily living self care…

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

Based on medical record review and staff interview, the facility failed to ensure residents were monitored for bowel movements and interventions for constipation were implemented as ordered. This affected three (#52, #23 and #30) of four residents reviewed for constipation. The facility census was 67. Finding include: 1. Review of Resident #52's medical record revealed an admission date of 06/14/23. Diagnoses included type II diabetes, major depressive disorder, anxiety disorder, polyneuropathy, and insomnia. Review of the MDS assessment, dated 05/20/24, revealed Resident #52 was severely cognitively impaired. Resident #52 was dependent on staff for toilet use and bathing. Resident #52 had hallucinations, delusions, and displayed rejection of care behaviors one to three days during the review period. Review of Resident #52's care plan, revised 05/20/24, revealed supports and interventions for use of psychoactive medications with risk for constipation, urinary and bowel incontinence and risk for constipation due to decreased mobility. Interventions for constipation included encourage…

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, resident interview, staff interview, and review of facility policy, the facility failed to ensure recommendations from the audiologist and optometrist were followed. This affected one (Resident #30) of one resident reviewed for vision and/or hearing. The facility census was 67. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, cognitive communication deficit, morbid obesity, major depressive disorder, anxiety disorder, and hallucinations. Review of the Minimum Data Set (MDS) assessment, dated 03/27/24, revealed the resident was moderately cognitively impaired. Further review of the MDS data revealed Resident #30's vision was adequate with corrective lenses and the hearing was not evaluated. Review of the care plan for Resident #30 revealed the facility will arrange consultation with eye care practitioner as required. Review of the optometry visit dated 10/19/22 revealed the resident complained of blurred vision to both eyes. The resident was identified with a…

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

Based on review of the medical record, observation, staff interview, review of manufacturer guidelines, and policy review, the facility failed to ensure a thorough wound assessment was completed and failed to provide appropriate pressure reducing devices. This affected one (#28) of three residents reviewed for pressure ulcers. The facility census was 67. Findings include Review of the medical record revealed Resident #28 had an admission date of 06/09/24. Diagnoses included multiple sclerosis, hypertension, dementia, and a pressure ulcer of the left buttock stage four. Review of the admission physician orders dated 06/09/24 revealed there were no orders for pressure reducing devices Review of the admission assessment completed on 06/09/24 at 5:16 P.M. noted the resident had a stage four pressure ulcer. There were no wound measurements or description of the wound documented. Review of a skin one-time observation tool, dated 06/10/24 at 4:02 P.M., revealed the resident had a stage four pressure ulcer to the left buttock measuring one centimeter (cm) in length by one cm in width by 1.6…

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, resident interview, and review of facility policy, the facility failed to obtain orders for the use and maintenance of an indwelling urinary catheter and failed to provide proper urinary catheter cleansing. This affected one (#64) of one sampled residents reviewed for indwelling urinary catheters in a facility census of 67. Findings include: Review of the medical record revealed Resident #64 admitted to the facility on [DATE]. Diagnoses included left radius fracture, arthrodesis, type 2 diabetes mellitus, age related osteoporosis with current pathological fracture, chronic kidney disease, anemia, hypertension, neuromuscular dysfunction of bladder, colostomy, and stenosis. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #64 with intact cognition and utilized an indwelling urinary catheter. Review of the care plan dated 12/11/23 addressed Resident #64's indwelling urinary catheter related to neurogenic bladder. Goals 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.

Based on resident interview, staff interview, medical record review, and review of the facility policy, the facility failed to ensure sliding scale insulin was provided as ordered for one (#34) of six residents reviewed for unnecessary medications. The facility census was 67. Finding include: 1. Review of Resident #34's medical record revealed an admission date of 10/15/20. Diagnoses included cerebral infarction, asthma, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. Review the Minimum Data Set (MDS) assessment, dated 03/19/24, revealed Resident #34 was cognitively intact. Resident #34 received insulin injections seven days during the review period. Resident #34 displayed no behaviors during the review period. Resident #34 required extensive assistance with bed mobility. Resident #34 was dependent on staff for toileting, and parts of dressing. Resident #34 required maximum assistance with bathing. Review of Resident #34's physician orders revealed an order…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure physician ordered laboratory (lab) testing was completed as indicated. This affected one resident (#35) of five residents reviewed for unnecessary medications. The facility census was 67. Findings Include: Review of Resident #35's medical record revealed an admission date of 02/09/18. Diagnoses included dementia, type II diabetes, major depressive disorder, psychosis, seizures, anxiety disorder, and insomnia. Review of Resident #35's physician orders revealed an order dated 10/12/21 for divalproex sodium (Depakote) tablet delayed release 250 milligrams (mg). Give 1 tablet by mouth two times a day related to seizures. An order dated 08/22/22 instructed to obtain valproic acid levels every six months due to Depakote drug therapy starting on 22nd. Review of Resident #35's laboratory (lab) results found no lab results for Resident #35's valproic acid levels. Review of Resident #35's 05/10/24 psychiatric note revealed Resident #35's labs were reviewed. There was no indication…

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, record review, and facility policy review, the facility failed to provide dental services to meet the residents needs. This affected one resident (#30) of one resident reviewed for dental. The facility census was 67. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, morbid obesity, major depressive disorder, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), hallucinations, osteoporosis, insomnia, intervertebral disc degeneration, spondylosis, spinal stenosis, hypertension (HTN), low back pain, cellulitis of right lower limb, and hyperlipidemia. Review of the Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the care plan for Resident #30 revealed they are at risk for oral/dental health problems related to many missing teeth. The facility will coordinate arrangements for dental care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and staff interview, the facility failed to ensure food provided to residents was palatable and attractive. This had the potential to affect all residents in the facility. The facility census was 67. Findings include: Review of the medical record for Resident #39 revealed an admission date of 02/09/23. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required set up assistance with eating. Review of Resident #39's care plan, revised 01/29/24, revealed supports and interventions for nutritional risk. Interview on 06/10/24 at 9:29 A.M. with Resident #39 reported her bacon was undercooked this morning and her food items were often not cooked well enough and cold. Observation on 06/10/24 at 12:34 P.M. of Resident #39's lunch tray found her to have been provided pizza 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 review of facility medical records, staff interview, and review of facility policies, the facility failed to ensure residents received influenza and pneumococcal immunizations. This affected two (#13 and #43) of five residents reviewed for influenza and pneumococcal immunizations in a facility with a census of 67. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, resistance to multiple antimicrobial drugs, generalized muscle weakness, atrial fibrillation, atherosclerosis of native arteries of extremities, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of facility immunization consent records revealed the facility obtained verbal consent from Resident #13 on 11/29/23 for the pneumococcal…

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 facility medical records, staff interview, and review of the facility policy, the facility failed to ensure residents received COVID-19 immunizations. This affected one (Resident #13) of five residents reviewed for COVID-19 immunizations in a facility with a census of 67. Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, resistance to multiple antimicrobial drugs, generalized muscle weakness, atrial fibrillation, atherosclerosis of native arteries of extremities, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of facility immunization consent records revealed the facility obtained verbal consent from Resident #13 on 11/29/23 for the COVID-19 immunization, but there was no documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, review of maintenance repair records, and review of facility policy, the facility failed to ensure all portions of resident call devices were functioning properly. This affected one resident (#58) of eight residents reviewed on the C Hall. The facility census was 67. Findings include: Review of Resident #58's medical record revealed an admission date of 02/01/23. Diagnoses included heart failure, cirrhosis of the liver, severe protein calories malnutrition, edema, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was moderately cognitively impaired. Resident #58 was dependent on staff for toilet use, bathing, and transfer. Resident #58 required moderate assistance with personal hygiene. Review of Resident #58's care plan revised 03/14/24 revealed supports and interventions for self-care deficit, risk for pain, risk for falls, and bowel and bladder incontinence. Interview on 06/10/24 at 9:54 A.M. 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 medical resident interview, staff interview, review of shower schedules and shower documentation, and review of a facility policy, the facility failed to ensure residents were showered as scheduled. This affected one (#70) of three residents reviewed for showers. The facility census was 71. Findings include: Review of the medical record for Resident #70 revealed an admission date of 03/03/24 with diagnoses of subarachnoid hemorrhage and assistance needed for personal care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 required moderate assistance with showering. Review of the care plan dated 03/08/24 for Resident #70 revealed she had an activities of daily living (ADLs) self-care performance deficit related to subarachnoid hemorrhage and required staff assistance with showering. Review of the shower schedule for Resident #70 revealed she was to have a shower on first shift on Wednesdays and Sundays. Review of the shower sheets for Resident #70 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 observation, staff interview, family and resident interviews, medical record review, review of the Resident Council meeting minutes, review of the facility assessment, and review of the staffing schedules, the facility failed to maintain staffing levels to meet the needs of the residents. This affected three residents (#8, #23 and #72) of four residents reviewed for showers and had the potential to affect all 74 residents who resided in the facility. The facility census was 74. Findings include: 1. Review of the Facility Assessment, dated 08/10/23 revealed an average daily census of 72 to 78 residents. Staffing to ensure resident care included one nurse to twenty-six residents and one state tested nursing aide (STNA) for every twelve residents for the night shift. Review of the staffing on 03/03/24 from 10:00 P.M. to 6:00 A.M. on 03/04/24 revealed three nurses and two STNA for a census of 74. Review of the Resident Council meeting minutes from 12/04/23 and 01/03/24 revealed there were resident concerns…

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 and family interview, staff interview, and policy review, the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living were provided showers as scheduled. This affected three (#8, #23 and #72) of four residents reviewed for activities of daily living. The facility census was 74. Finding include: 1. Review of the medical record for Resident #8 revealed an admission date of 02/22/24. Diagnoses included respiratory failure with hypoxia and diabetes mellitus type II. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment, required moderate assistance from staff for showers and bathing. Review of the care plan dated 03/03/24 revealed Resident #8 had an activities of daily living self care deficit and required assistance with bathing. The identified goal for Resident #8 was to improve in all areas of activities of daily living self performance. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to provide appropriate incontinence care to residents. This affected two (Residents #16 and #69) of three residents observed for incontinence care. The facility census was 74. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 02/10/24. Diagnoses included chronic obstructive pulmonary disease and periprosthetic fracture around other internal prosthetic joint. Review of the care plan dated 02/02/24 revealed Resident #16 experienced a performance deficit related to activities of daily living, and was incontinent of urine and bowel. Interventions included assistance with personal care as needed, the use of disposable briefs and cleansing of the perineum after each episode of incontinence. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderate cognitive impairment, required substantial assistance for toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered according to physician's orders, resulting in a medication error rate which exceeded five percent. 25 opportunities were observed with two medication errors, resulting in 8.0 percent error rate. This affected one (Resident #51) of five residents observed for medication administration. The facility census was 74. Findings include: Review of the medical record revealed Resident #51 was admitted on [DATE]. Diagnoses included congestive heart failure, diabetes mellitus type II, and vascular dementia. Review of the care plan dated 04/27/21 and last revised on 07/25/23 revealed Resident #51 had diabetes and interventions included for diabetes medication to be administered as ordered. Resident #51 also had a care plan dated 10/27/20 with a revision date of 07/25/23 for congestive heart failure. Interventions included for cardiac medications to be administered as…

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

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure call lights were within reach and accessible for residents. This affected two residents (#11 and #17) of ten residents reviewed for call light placement. The Facility census was 76. Findings Include: 1. Review of the medical record for Resident #11 revealed an admission date of 08/12/23. Diagnoses included type II diabetes mellitus, anxiety disorder, anemia, chronic kidney disease, hypothyroidism, hypertension, major depressive disorder, peripheral vascular disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 08/16/23, revealed Resident #11 had cognitive impairment, was total dependence of two staff for bed mobility and personal hygiene and had no functional limitations of the upper extremities. Observation on 12/11/23 at 9:00 A.M. of Resident #11 revealed the call light cord was hanging from the reset box in the room at the foot of the resident's bed and outside the reach of the resident. Concurrent interview with Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and review of facility policy the facility failed to ensure dependent residents were provided feeding assistance with meals. This affected two Residents (#17 and #21) of three residents reviewed for feeding assistance. The facility identified eleven residents that required feeding assistance. The facility census was 76. Findings include: 1. Review of medical record for Resident #17 revealed an admission date of 03/09/23. Diagnoses included metabolic encephalopathy. mild protein calorie malnutrition, end stage renal disease, dysphagia, dementia, and impaired visual loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/03/23, revealed Resident #17 was moderately cognitively impaired, was highly impaired visually with object identification in question, required set up with meals to ensure awareness of what food was served, the location on the plate and to provide eating utensils. Review of the care plan dated 03/09/23 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 medical record review, review of a community referral form, staff interview and review of facility policy, the facility failed to complete assessments on new admission to timely meet residents needs. This affected one (#87) of three residents reviewed for discharge. The facility census was 76. Findings include: Review of the medical record for Resident #87 revealed an admission date of 11/16/23 at 5:02 P.M. and a discharge date of 11/16/23 with a time of 7:03 P.M. Diagnoses included osteoarthritis of right hip, hyperlipidemia, gastroesophageal reflux, and obesity. Resident #87 had a right hip replacement on 11/15/23 and was being admitted to the facility for therapy to improve balance, strength, and endurance prior to returning home. Plan for services were needed for less than 30 days. Review of the community referral form dated 11/16/23 and timed 1:03 P.M. revealed Resident #87 was ordered to receive aspirin 81 milligrams (mg) once a day, extra strength Tylenol 1000 mg every eight hours as needed for pain for 14 days, celecoxib 200 mg once daily for 14 days, vitamin D3…

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

Based on observation, medical record review, staff interview, review of the manufacturer's recommendations and review of the facility policy on insulin administration, the facility failed to ensure insulin was administered as ordered. This affected one (#7) of four residents reviewed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #7 revealed an admission date of 11/06/20. Diagnoses included metabolic encephalopathy, type II diabetes mellitus, anxiety disorder, and hypertension. Review of the current physician orders for Resident #7 revealed an order dated 10/05/22 for 26 units of insulin glargine to be injected subcutaneously one time a day using a Basaglar Kwik pen Solution Pen-Injector 100 units per milliliter (ml). Observation on 12/11/23 at 9:10 A.M. of insulin administration for Resident #7 with Licensed Practical Nurse (LPN) #558 revealed LPN #558 removed an insulin pen from the top drawer of the medication cart, followed by pen needle and alcohol wipes. LPN #558 closed the drawer, removed the cap from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and review of facility policy, the facility failed to ensure a functional call light system. This affected one (#11) of ten residents reviewed for call lights. The facility census was 76. Findings include: Review of Resident #11's medical record revealed an admission date of [DATE]. Diagnoses included type II diabetes mellitus, anxiety disorder, anemia, chronic kidney disease, hypothyroidism, hypertension, major depressive disorder, peripheral vascular disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #11 had cognitive impairment, required total dependence of two staff for bed mobility and personal hygiene, and had no functional limitations of the upper extremities. Observations on [DATE] at 8:00 A.M. and from 10:20 A.M. to 10:45 A.M., when care was being provided by State Tested Nursing Assistant (STNA) #587, revealed the call light alert outside Resident #11's room was lit. Interview on [DATE] at 10:45 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents who required assistance from staff with activities of daily living received showers/bed baths as scheduled. This affected two (#10 and #13) of three residents reviewed for hygiene. The facility census was 76. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, spinal stenosis, and age related osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 09/08/23, revealed Resident #13 was cognitively intact. Resident #13 required staff assistance with bathing. Review of the care plan, revised 02/14/23, revealed Resident #13 had activities of self care performance deficit and interventions included the resident was dependent on staff for showers. Review of the shower sheets, dated 09/04/23 to 10/04/23, revealed Resident #13 had three documented bed baths in the…

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

Based on observations, resident and staff interviews, and facility policy review, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected of thee (#10, #13, and #21) of three residents reviewed for physical environment. The facility census was 76. Findings include: Observation on 10/04/23 at 8:55 A.M. of Resident #10's room revealed the bathroom floor was stained and dirty, the blinds covering the large window near the bed had splatters of possibly food or drink and were covered with a thick dust, the valance above the window had a think layer of dust, and the wall vent had a thick layer of dust. Interview on 10/04/23 at 8:59 P.M. with Resident #10 revealed his room was not cleaned well and pointed to the window blinds. Resident #10 stated the bathroom floor was always dirty. Interview on 10/04/23 at 9:11 A.M. with Housekeeping #201 verified Resident #10's bathroom floor, blinds, window valance, and vent were not appropriately clean. Interview on 10/04/23 at 10:38 A.M. with Resident #13 revealed the carpet in her room was stained…

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

Based on review of facility documents and staff interview, the facility failed to verify residents with a trust fund account received quarterly bank statements. This affected 37 (#6, #8, #9, #10, #12, #15, #16, #17, #18, #21, #22, #23, #24, #25, #26, #29, #30, #31, #32, #33, #34, #35, #37, #39, #40, #43, #44, #50, #51, #53, #57, #64, #65, #66, #67, #69, and #71) of 37 residents with a resident trust fund account. The facility census was 70. Findings include: Interview on 06/16/22 at 11:05 A.M., with the Business Office Manager #438 revealed she could not verify the facility had provided quarterly statements to residents or their representatives who had trust fund accounts with the facility. Further interview revealed the facility had 37 (#6, #8, #9, #10, #12, #15, #16, #17, #18, #21, #22, #23, #24, #25, #26, #29, #30, #31, #32, #33, #34, #35, #37, #39, #40, #43, #44, #50, #51, #53, #57, #64, #65, #66, #67, #69, and #71) residents with a trust fund account. Review of the undated facility documented titled, Authorization to Manage Resident Trust Fund revealed residents with an account…

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, and record review, the facility failed to ensure a resident received proper care and treatment to improve maintain hearing abilities. This affected one (#22) of two residents reviewed for communication. The facility census was 70. Findings include: Review of the medical record for Resident #22 revealed an admission date of 03/07/19, with diagnoses including hypothyroidism, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment completed on 04/11/22 revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Review of MDS assessments dated 06/11/19, 09/04/19, 11/07/19, 02/14/20, 04/10/20, 07/03/20, 10/02/20, 04/08/21, 07/08/21, 08/27/21, 10/15/21, 01/12/22, and 04/11/22 revealed the resident had moderate difficulty with hearing and did not have hearing aids. MDS assessments dated 12/13/20 and 01/18/21 indicated the resident's hearing was highly impaired and the resident had no hearing aids. Review of hospital documentation with a 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 record review, observation, resident and staff interviews, the facility failed to ensure a resident was turned and repositioned every two hours per the plan of care to prevent skin breakdown. This affected one (#6) of one resident reviewed for turning/repositioning to prevent skin breakdown. The facility identified three current residents with pressure sores and 61 residents receiving preventive skin care. Facility census was 70. Findings include: Review of the medical record reviewed Resident #6 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, anxiety, and depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required the extensive assistance of two staff for bed mobility. The resident was noted to be cooperative with care. Review of the pressure sore risk assessment dated [DATE] revealed the resident was at high risk for development of pressure sores. Review of Resident #6's plan of care dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, family and staff interview, review of safety data sheets, and review of the safety manual, the facility failed to securely store hazardous materials. This affected one (Resident #46) of two facility identified independently mobile, cognitively impaired residents. The facility census was 70. Findings include: Review of the medical record for Resident #46 revealed an admission date of 10/06/21, with diagnoses of malignant neoplasm of overlapping sites of colon, dementia, and intervertebral disc degeneration lumbar region. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #46 had impaired cognition and required limited assistance of one person for transfers and walking. Review of the medical record for Resident #19 revealed an admission date of 06/17/21, with diagnoses of cardiomegaly, nonrheumatic aortic valve stenosis, and hypertensive heart disease without heart failure. Observation on 06/13/22 at 11:05 A.M., revealed bottles of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the policy, and staff interview, the facility failed to ensure the proper psychiatric diagnoses was in the medical record for a resident receiving anti-psychotic medications. This affected one (#75) of five residents reviewed for anti-psychotic medications. The facility identified 13 residents utilizing antipsychotic. The current census is 70. Findings include: Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses include: dementia, encephalopathy, muscle weakness, falls, anxiety and depression. Review of Resident #75's comprehensive Minimum Data Set, (MDS) assessment dated [DATE], revealed the resident impaired cognition, was a 1-2 person assist with Activities of Daily Living (ADL), and was receiving antipsychotics. Per the MDS assessment the resident has non-Alzheimer's dementia. No psychosis diagnoses was noted in the assessment. Per the MDS dated [DATE], the resident was not diagnosed with bipolar, psychotic…

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, policy review, resident and staff interviews, the facility failed to ensure all medications were secured during medications administration for residents. This affected two (#5 and #18) of five residents reviewed for medication administration. The current census is 70. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 05/13/19, with diagnoses including: heart failure, hypertension, depression, and ischemic heart failure. Review of Resident #18's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a set up for ADLs. Review of Resident #18's care plans dated 05/2019 revealed a focus for an Activities of Daily Living (ADL) self-care performance related to heart failure and receiving hospice services. Interventions include praise efforts for self-care, provide care for ADLs and monitor for changes. Review of Resident #18's physician prescribed medications revealed all…

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 employee personnel files, staff interview and facility policy, the facility failed to ensure state tested nursing assistants (STNA) had performance evaluations completed every 12 months. This affected five STNA's (#112, #122, #139, #150 and #151) of 10 nurse aide employee files reviewed. This had the potential to affect all 95 residents residing in the facility. The facility census was 95. Findings include: 1. Review of STNA #150's personnel file revealed a date of hire of 04/11/18. STNA #150's annual evaluation had not been completed in April 2019. 2. Review of STNA #151's personnel file revealed a date of hire of 04/05/18. STNA #151's annual evaluation had not been completed in April 2019. 3. Review of STNA #139's personnel file revealed a date of hire of 04/03/78. STNA #139's annual evaluation had not been completed in April 2019. 4. Review of STNA #122's personnel file revealed a date of hire of 05/31/17. STNA #122's annual evaluation had not been completed in May 2019. 5. Review of STNA #112's personnel file revealed a date of hire of 02/25/15. STNA #112's…

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

Based on observation, staff interview, review of the facility infection control data log and facility policy, the facility failed to ensure urinary and colostomy collection devices were properly stored. This affected five (#31, #190, #44, #88, #53) of six residents who had urinary/colostomy collection devices in their rooms and not covered. This had the potential to affect all 95 residents who reside in the facility. In addition, the facility failed to ensure a proper infection control monitoring system was in place. The facility census was 95. Findings include: 1. Observation on 07/24/19 between 10:45 A.M. and 11:00 A.M. of Residents (#31, #44, #53, #88, #190) bathrooms revealed urinary catheter collection devices were on the back of the toilets uncovered with no barrier on the bottom of the collection devices. In addition, Resident #31 also had a colostomy collection device sitting on the back of the toilet uncovered with no barrier in place. Interview on 07/24/19 at 11:00 A.M. with Registered Nurse (RN) #300 verified Residents #31, #44, #53, #88 and #190's collection devices 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 observation and resident and staff interview, the facility failed to ensure residents were served meals in a dignified manner. This affected 16 (#9, #70, #5, #90, #86, #29, #85, #4, #3, #46, #64, #32, #16, #42, #2 and #25) of 16 residents who received meals in the main dining room. The facility census was 95. Findings include: Observation of the lunch meal on 07/22/19 between 12:15 P.M. and 12:45 P.M. revealed 16 (#9, #70, #5, #90, #86, #29, #85, #4, #3, #46, #64, #32, #16, #42, #2 and #25) residents were seated at 12 tables. On 07/22/19 at 12:30 P.M. the first resident meal was served in the dining room, Resident #42 was served first. There was one other resident (#16) at his table at that time who was not offered their lunch tray. Staff were then observed to serve Resident #32 who was seated at another table. Staff were then observed to skip the second resident at that table (Resident #64) and went to Resident #46 who was at another table with three additional residents (#3, #85, #4). These three residents were skipped and staff served Resident #70 at another table. Two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interview and review of a facility policy, the facility failed to ensure medications were dated when they were opened. This affected four resident's (#7, #40, #64, #390) of 30 resident's whom resided on the B hall. Additionally, the facility failed to ensure staff observed residents during medication administration to ensure the resident took/consumed their medication. This affected two residents' (#15 and #190) of six residents reviewed for medications. The facility census was 95. Findings include: 1. Medical record review revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. Review of the resident's physician orders revealed the resident had an active order, dated 06/04/19, for Advair Diskus (bronchodilator used to treat asthma and chronic bronchitis, including COPD associated with chronic bronchitis) one puff by inhalation twice a day for COPD. Observation 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, family and staff interview, and review of facility policy, the facility failed to ensure residents were bathed as desired. This affected one (#11) out of four residents reviewed for choices. The facility census was 95. Findings include: Review of Resident #11's medical record revealed an admission date of 09/02/17. Diagnoses included chronic obstructive pulmonary disease, dementia, muscle weakness, lymphedema, hypertension, dizziness and giddiness, anxiety disorder, obesity, insomnia, radiculopathy of cervical region, anemia, and chronic kidney disease. Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #11 was cognitively intact. Resident #11 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #11 required limited assistance with walking, and locomotion. Resident #11 displayed no behaviors during the review period. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, resident, family and staff interview and policy review, the facility failed to ensure residents and responsible parties were provided a written notice of transfer upon discharge from the facility to a hospital. This affected two (#37 and #53) of two residents reviewed for hospitalizations. The facility identified six residents discharged from the facility to acute care facilities. The facility census was 95. Findings include: 1. Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia affecting left side, muscle weakness, cerebral infarction, lymphedema, hypertension, diabetes mellitus type II, hypothyroidism, osteoarthritis and epidermal cyst. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits and required extensive assistance with activities of daily living. Review of progress notes dated 03/27/19…

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, family and staff interview and policy review, the facility failed to ensure residents and responsible parties were provided a bed hold policy upon discharge from the facility to a hospital. This affected two (#37 and #53) of two residents reviewed for hospitalizations. The facility identified six residents discharged from the facility to acute care facilities. The facility census was 95. Findings include: 1. Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia affecting left side, muscle weakness, cerebral infarction, lymphedema, hypertension, diabetes mellitus type II, hypothyroidism, osteoarthritis and epidermal cyst. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits and required extensive assistance with activities of daily living. Review of progress notes dated 03/27/19 at 4:45 A.M. revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff, resident and family interview and policy review, the facility failed to provide oral care to a resident. This affected one resident (#37) of three residents reviewed for activities of daily living. The facility identified 24 residents who required assistance with oral care. The facility census was 95. Findings include: Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia affecting left side, muscle weakness, cerebral infarction, lymphedema, hypertension, diabetes mellitus type II, hypothyroidism, osteoarthritis and epidermal cyst. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits and required extensive assistance with activities of daily living. The resident did not refuse care. Review of the resident's plan of care revealed the resident required assistance with personal hygiene. Review of State Tested Nursing…

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 review of a facility policy, the facility failed to obtain a physician's order for a resident's skin treatment. This affected one (#15) of five residents reviewed for skin conditions. The facility census was 95. Findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included neoplasm of unspecified bone, soft tissue and skin, malignant neoplasm of the prostate and hypertension. Review of the quarterly Minimum Data Set assessment, dated 04/13/19, revealed the resident was cognitively intact. The resident did not have any wounds. Review of a Skin Observation Tool, dated 07/08/19, revealed the resident had a tumor on the front of his left lower leg that measures approximately one centimeter long by one centimeter wide. The wound was not open. The resident had his own bandage on the tumor site. The nurse removed the dressing, cleaned the site and covered it with a foam bandage.…

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 a facility policy, the facility failed to ensure non-pharmacological interventions were attempted prior to administering as needed psychotropic medications. Additionally, the failed to ensure as needed psychotropic medications were limited to 14 days. This affected two residents (#52 and #87) of six residents reviewed for unnecessary medications. The facility census was 95. Findings include: 1. Medical record review revealed Resident #52 admitted to the facility on [DATE]. Diagnoses included Diabetes mellitus, heart failure and anxiety. Review of the quarterly Minimum Data Set assessment, dated 06/14/19, revealed the resident had impaired cognition. Review of the the resident's physician orders revealed the resident had an active order dated 12/10/18 for Alprazolam 0.5 milligrams (anti-anxiety medication) to be administered as needed (PRN) up to three times a day. The record review revealed no documentation was found regarding if the Physician…

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.