Aventura At Shiloh Springs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews, review of information from Medscape and review of information from the National Library of Medicine, the facility failed to ensure bowel movements were monitored for residents at risk of constipation. This affected one (#2) out of two residents reviewed for constipation. The census was 55. Findings include: Review of Resident #2's medical record revealed and admission dated of 12/04/25. Diagnoses listed included bacteremia, hypertension, cellulitis, type two diabetes mellitus, and osteomyelitis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Review of physician orders revealed an order dated 12/11/25 for oxycodone hydrochloride (narcotic pain medication) oral tablet 5 milligrams (mg) by mouth four times a day for pain. Further review of Resident #2's medical record revealed no documentation of bowel movements being monitored. There was not any documentation of Resident #2's last bowel movement.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff and resident interviews, the facility failed to ensure a resident's indwelling urinary catheter (Foley) was attempted to be removed as ordered. This affected one (#2) of one reviewed for Foley catheter care. The census was 55. Findings include: Review of Resident #2's medical record revealed and admission dated of 12/04/25. Diagnoses listed included bacteremia, hypertension, cellulitis, type two diabetes mellitus, and osteomyelitis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Review of physician orders revealed an order dated 12/30/25 to clamp Foley times four hours then release times 15 minutes, repeat times 24 hours then discontinue Foley. If no voiding may straight catheter every four to six hours and as needed. If post void residual is greater than 500 milliliters times two times replace foley. Further review Resident #2's medical record revealed no documentation of Resident #2's Foley being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, and review of facility policy, the facility failed to ensure staff cared for a resident's tracheostomy appropriately. This affected one (#10) of one residents reviewed for tracheostomy care. The census was 55. Findings include: Review of Resident #10's medical record revealed an admission date of 01/21/25. Diagnoses listed included chronic obstructive pulmonary disease, coronary artery disease, anxiety disorder, hemiplegia, encephalopathy, and psychotic disturbance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was rarely understood by staff and received tracheostomy (trach) care. Review of Resident #10's medical record revealed the resident had a trach which was being cared for by nursing staff. Resident #10's tracheostomy care being completed by Licensed Practical Nurse (LPN) #201 was observed on 01/07/25 at 2:05 P.M. LPN #201 removed gloves used during feeding tube care. LPN #201 did not sanitize or wash 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.

Based on medical record review, staff interview, interview with dialysis staff, review of dialysis treatment logs, and policy review, the facility failed to ensure pre and post dialysis evaluations were completed, failed to ensure communication with dialysis center was consistently done, failed to ensure the medical record contained documentation related to missed dialysis treatments, and failed to ensure the physician was notified of missed dialysis treatments. This affected the one (#03) of one residents reviewed for dialysis services. The facility census was 55. Findings include: Review of the medical record for Resident #03 revealed an admission date of 09/17/25 with medical diagnoses of intracranial hemorrhage, left hemiparesis, end stage renal disease (ESRD), and dependence on dialysis. Review of the medical record for Resident #03 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, which indicated Resident #03 was cognitively intact and required partial/moderate staff assistance with toilet hygiene and showers, and supervision with transfers. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure medications were not left at a resident's bedside. This affected one (#50) out of 55 residents observed during the initial pool. The census was 55. Findings include: Review of Resident #50's medical record revealed an admission date of 09/18/25. Diagnoses listed include atrial fibrillation, heart failure, hypertension, malnutrition, and post-traumatic stress disorder. Review of a quarterly Minimum data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact. Further review of Resident #50's medical record revealed the nursing staff were to administer the residents medication and there was no assessment, order or care plan for the resident to self-administer medications. Observation on 01/05/26 at 11:22 A.M. revealed several pills in a medication cup and a bottle of Flonase (nasal spray) on a bedside table in Resident #50's room. Interview and observation with Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, staff interviews, and policy review, the facility failed to ensure laboratory (labs) values were obtained as per physician orders. This affected three (#02, #03, and #09) residents out of five residents reviewed for lab services. The facility census was 55. Findings include: 1. Review of the medical record for Resident #03 revealed an admission date of 09/17/25 with medical diagnoses of intracranial hemorrhage, left hemiparesis, end stage renal disease (ESRD), and dependence on dialysis. Review of the medical record for Resident #03 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, which indicated Resident #03 was cognitively intact and required partial/moderate staff assistance with toilet hygiene and showers, and supervision with transfers. The MDS indicated Resident #03 was independent with bed mobility and Resident #03 received dialysis. Review of the medical record for Resident #03 revealed a physician order dated 09/29/25 for complete blood count (CBC)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure staff implemented enhance barrier precautions (EBP). This affected one (#10) of five reviewed for transmission-based precautions (TBP). The census was 55. Findings include: Review of Resident #10's medical record revealed an admission date of 01/21/25. Diagnoses listed included chronic obstructive pulmonary disease, coronary artery disease, anxiety disorder, hemiplegia, encephalopathy, and psychotic disturbance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was rarely understood by staff and received tracheostomy care. Review of physician orders revealed an order date 09/24/25 for EBP due to the presence of a tracheostomy and feeding tube. Observation of Resident #10's trach care and medication administration per feeding tube on 01/07/2026 2:05 P.M. revealed Licensed Practical Nurse (LPN) #201 did not don a gown when providing care. LPN #201 accessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and review of facility policy, the facility failed to ensure residents were supervised while smoking and further failed to ensure residents smoked in designated areas per facility policy. Additionally, the facility failed to ensure residents utilized non-combustible containers to extinguish smoking materials. This affected two (#21 and #07) of two residents reviewed for smoking. The facility identified 15 (#07, #08, #13, #15, #16, #20, #21, #24, #26, #32, #34, #43, #48, #49, and #50) residents who smoked. The facility census was 50.Findings include:1. Review of the medical record for Resident #21 revealed an admission date of 02/13/24 with medical diagnoses of chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), and tobacco use.Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/11/25, revealed Resident #21 was cognitively intact and was independent with all activities of daily living (ADLs).Review of the current plan of care revealed Resident #21 was at risk for injury 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 record review, staff interviews and policy review, the facility failed to provide notification to the physician or family for a newly identified pressure ulcer. This affected one (#10) of three reviewed for pressure ulcers. care. The facility census was 56. Findings include: Review of medical record for Resident #10 revealed admission date of 01/30/25. The resident was hospitalized [DATE] and did not return. The resident was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus and hypertension. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required was independent for eating, moderate assistance for bed mobility, toileting hygiene and transfers were not attempted. Documentation revealed no pressure ulcers upon admission to the facility. Record review of the 02/06/25 skin assessment documented a nine centimeter (cm) by (x) 11.0 centimeter unstageable sacral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide assistance with personal hygiene and Activities of Daily Living (ADL). This affected one (#10) of three residents reviewed for ADL care. The facility census was 56. Findings include: Review of medical record for Resident #10 revealed admission date of 01/30/25. The resident was hospitalized [DATE] and did not return. The resident was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus and hypertension. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required was independent for eating, moderate assistance for bed mobility, toileting hygiene and transfers were not attempted. She required moderate assistance with showering and bathing. A care plan revealed alterations in bladder elimination related to incontinence with interventions to assist with toileting needs and incontinence care on routine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, interviews with staff and Wound Physician and policy review, the facility failed to provide appropriate care and services to pressure ulcers. This affected two (#10 and #11) of three reviewed for pressure wounds. The facility census was 56. Findings include: 1. Review of medical record for Resident #10 revealed admission date of 01/30/25. The resident was hospitalized [DATE] and did not return. The resident was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus and hypertension. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required was independent for eating, moderate assistance for bed mobility, toileting hygiene and transfers were not attempted. Documentation revealed no pressure ulcers upon admission to the facility. Record review of the 02/06/25 skin assessment documented a nine centimeter (cm) by (x) 11.0 centimeter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a hospital referral and interviews with staff, the facility failed to provide timely therapy services. This affected one (#10) of three residents reviewed for therapy services. The facility census was 56. Findings include: Review of medical record for Resident #10 revealed admission date of 01/30/25. The resident was hospitalized [DATE] and did not return. The resident was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus and hypertension. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required was independent for eating, moderate assistance for bed mobility, toileting hygiene and transfers were not attempted. She required moderate assistance with showering and bathing. Review of the hospital referral for Resident #10 revealed orders for both Physical Therapy (PT) and Occupational Therapy (OT) services to continue at discharge.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, staff interviews and policy review, the facility failed to ensure proper infection control procedures were followed during resident care. This affected one (#12) out of three residents reviewed for infection control. The facility census was 56. Findings include: Review of medical record for Resident #12 revealed admission date of 10/21/23 and admitted to hospice on 09/01/24. The resident was admitted with diagnoses including hemiplegia, diabetes mellitus, depression and gastronomy tube (g-tube). The resident remained in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had significant impaired cognition. He was dependent for eating, bed mobility, transfers and toileting hygiene. He was documented as always incontinent of urine and bowel. Further review of Resident #12's medical record revealed the resident had a wound on the buttock that required treatments. Observation on 03/11/25 at 10:38 A.M. with Licensed Practical Nurse (LPN) #13 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to maintain and clean and sanitary environment. This affected two (#13 and #34) of six resident's rooms observed for environmental cleanliness. The facility census was 59. Findings Included: 1. Review of the medical record for Resident #34 revealed an admission date 12/15/24. Diagnoses included chronic diastolic heart failure, cognitive communication deficit, atrial flutter, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was assessed with severely impaired cognition. Observation on 01/22/25 at 11:01 A.M. of Resident #34's room revealed the floor to the left side of the bed had 25 circular brownish-black marks approximately two to three inches in diameter scattered on the floor. The floor was also noted to be dirty and stained, and the wall edges in the room were covered with black, hard dirt from approximately two to three inches 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, resident and staff interview, medical record review, and facility policy review, the facility failed to provide timely care and services when answering call lights. This affected one (#29) of three residents reviewed for call light response. The facility census was 59. Findings Included: Review of the medical record for Resident #29 revealed an admission date of 11/11/24. Diagnoses included bipolar disorder, type two diabetes, morbid obesity, anxiety, and major depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was assessed with intact cognition, required partial to moderate assistance with bathing, toileting hygiene, personal hygiene, dressing the lower body, placing shoes on and off the feet, and required a walker to ambulate. Review of a plan of care dated 12/31/24 revealed Resident #29 was at risk for impaired activities of daily living (ADLs) related to requiring assistance to perform and complete ADLs, weakness, asthma, diabetes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to provide timely pain medication as ordered to effectively treat pain. This affected one (#3) of three residents reviewed for pain management. This facility census was 59. Findings Included: Review of the medical record for Resident #3 revealed a most recent admission date of 01/10/25. Diagnoses included cellulitis of the right lower limb, acute kidney failure, major depressive disorder, and hypertension. Review of the Minimum Data Set (MDS) assessment MDS dated [DATE] revealed Resident #3 was assessed with moderately impaired cognition. Review of a physician order dated 01/10/25 revealed Resident #3 had an order for the narcotic pain medication oxycodone immediate release (IR) five (5) milligrams (mg) to take one tablet by mouth every eight hours as needed for pain. Review of Resident #3's plan of care dated 01/11/25 revealed the resident received pain medication, received therapy, and had neuropathy.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to ensure blood glucose levels were adequately monitored as ordered to determine the need for sliding scale insulin. This affected one (#13) of three residents reviewed for insulin usage. The facility census was 59. Findings Included: Review of the medical record revealed Resident #13 had an admission date 11/06/24. Diagnoses included type two diabetes, alcohol dependence, bipolar disorder, major depressive disorder, acute kidney failure, and hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was assessed as cognitively intact. Review of a plan of care dated 11/06/24 revealed Resident #13 had the potential for hypoglycemia or hyperglycemia related to diabetes. Interventions included to obtain blood glucose checks per physician order and as needed, administer medication as ordered, educate resident regarding signs and symptoms of hyperglycemia or hypoglycemia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to ensure medication administration records were accurately documented to reflect blood glucose monitoring. This affected one (#13) of three residents reviewed for insulin usage. The facility census was 59. Findings Included: Review of the medical record revealed Resident #13 had an admission date 11/06/24. Diagnoses included type two diabetes, alcohol dependence, bipolar disorder, major depressive disorder, acute kidney failure, and hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was assessed as cognitively intact. Review of a plan of care dated 11/06/24 revealed Resident #13 had the potential for hypoglycemia or hyperglycemia related to diabetes. Interventions included to obtain blood glucose checks per physician order and as needed, administer medication as ordered, educate resident regarding signs and symptoms of hyperglycemia or hypoglycemia, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to ensure the administration of as needed medication was documented in the resident's medical record. Additionally, the facility failed to document care and services related to incontinent care and application of durable medical equipment as ordered. This affected three (#15, #45 and #18) of three residents reviewed for medical record accuracy. The facility census was 42. Findings include: 1. Medical record review for Resident #45 revealed an admission on [DATE] and a discharge to the hospital on [DATE]. Diagnoses include congestive obstructive pulmonary disease, chronic respiratory failure with hypoxia, sleep apnea, atrial fibrillation, anxiety disorder, obesity, and fracture of right fibula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 revealed an intact cognition. Resident #45 required moderate assistance with eating, dependent for toileting, max assistance for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, review of the facility's self-reported incident (SRI) and investigation, and policy review, the facility failed to prevent resident-to-resident physical abuse when a resident struck another resident with a cane, and a third resident came up behind the resident and struck the same resident. This affected one (Resident #19) of three residents reviewed for abuse. The facility census was 51. Findings include: Review of the facility's SRI dated 07/09/24 revealed Resident #19 reported an allegation of physical abuse by two other residents to Licensed Practical Nurse (LPN) #287. Resident #19 reported that Resident #41 struck him across the face while outside in the courtyard and Resident #52 used his hand to hit the back of his head. No injuries noted at time of incident. Review of the investigative notes dated 07/09/24 revealed Resident #41 and #52 denied the allegations. On 07/10/24, Resident #52 confirmed he came up behind Resident #19, swung, hitting him 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to prevent elopement. This affected one (Resident #24) of three reviewed for elopement. The facility census was 48. Findings include: Review of the medical record of Resident #24 revealed an admission date of 02/01/24. Diagnoses included Wernicke's encephalopathy and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively impaired and required maximal assistance with activities of daily living. Review of the Wander Risk Evaluation dated 02/02/24 revealed Resident #24 was at a risk for wandering. The form did not indicate any interventions to be care planned. Review of the admission Nursing Evaluation dated 02/02/24 revealed Resident #24 was alert, confused, and oriented to name only. The form indicated Resident #24 experienced hallucinations, delusions, and resists care. Review of the care plan revealed an entry dated 03/20/24 indicating Resident #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, medical record review, staff interview, and review of the policy, the facility failed to ensure medications were administered timely. This affected one resident (#12) of four observed for medication administration. The facility census was 48. Findings include. Observation on 07/02/24 at 10:39 A.M. revealed Licensed Practical Nurse (LPN) #191 administering medications to Resident #12. The medications included one docusate 100 milligrams (mg), one Eliquis 2.5 mg tablet, one multivitamin tablet, one gabapentin 300 mg tablet, one Keppra 500 mg tablet, one spironolactone 25 mg tablet, one nicotine patch 7 mg, one puff of Advair 21 microgram, , and one vitamin D3. The gabapentin was ordered to be given three times daily and scheduled for 9:00 A.M., 1:00 P.M., and 5:00 P.M. Interview on 07/02/24 at 10:45 A.M. with LPN #151 revealed the medications were administered late and the gabapentin would have to be delayed for the next two administrations. Review of the policy tilted, Administering Medications, dated 08/2023 revealed medications are to be administered in a safe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staffing schedules and staff interviews, the facility failed to provide eight hours of continuous Registered Nurse (RN) care seven days a week as required. This had the potential to affect all 47 residents residing in the facility. The facility census was 47. Findings include: Review of the facility staffing schedules for dates 11/21/23 through 11/27/23 revealed there was no Registered Nurse (RN) coverage on 11/25/23 or 11/26/23. On 11/29/23 at 2:57 P.M. an interview with the Administrator confirmed the facility did not have RN coverage on 11/25/23 or 11/26/23. This deficiency represents non-compliance investigated under Complaint Number OH00147602.

Based on observations, staff interviews, review of dishwasher logs and manufacturers instructions, the facility failed to ensure the dishwasher temperatures and sanitation was being followed as per manufacturer instructions. This had the potential to affect 44 out of 45 residents residing in the facility, two (#39 and #46) residents did not receive their meals from the kitchen. The facility census was 47. Findings include: 1. Observation with Dietary Manager #1 on 11/28/23 at 10:22 A.M. in the facility kitchen of the dishwasher revealed the wash cycle temperature was 86 degrees Fahrenheit (F) and the rinse cycle was 98 degrees F. Several cycles were performed with the wash cycle increasing to 100 degrees F and the rinse cycle to 110 degrees F. On 11/28/23 at 10:22 A.M. Dietary Manager #1 confirmed the dishwasher was not reaching the appropriate temperature. Record review of the dishwasher log revealed for breakfast the wash cycle was 110 degrees F on 11/20/23, 11/22/23 11/26/23; rinse cycle for breakfast was 110 degrees F on 11/20/23; and 115 degrees F on 11/24/23, 11/25/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete an admission assessment on a newly admitted residents. This affected one (#33) of three residents reviewed who were newly admitted . The facility census was 47. Findings include: Review of medical record for Resident #33 revealed admission date of 10/10/23. Medical diagnoses included but were not limited to personal history of bladder cancer, lung cancer, conjunctival edema right eye, ocular pain right eye and diabetes mellitus type II. The resident remains in the facility. Review of Resident #33's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. He required set up for meals, substantial assistance for toileting, supervision for bed mobility and no documentation for transfers. Record review of the electronic medical record for Resident #33 revealed the MDS entry date was documented as 10/10/23. The census documented the actual admission date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review the facility failed to ensure medications were administered as ordered. This affected two (#57 and #33) of four residents reviewed for medication administration. The facility census was 47. Findings include: 1. Review of medical record for Resident #57 revealed admission date of 7/23/23. Medical diagnoses included but were not limited to end stage renal disease and chronic obstructive pulmonary disease. The resident was discharged on 09/29/23. Review of Resident #57's discharge Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required extensive assistance for bed mobility, transfers, toileting and supervision for eating. Review of Resident #57's September 2023 Medication Administration Record (MAR) revealed no documentation Carvedilol (hypertension) 25 milligrams (mg) was given at 9:00 P.M. on 09/05/23; Gabapentin (neuropathy)100 mg (pain), Simethicone (gas) 80 mg, Calcium Acetate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, staff interviews and review of manufacturer instructions, the facility failed to ensure medications were administered as physician orders resulting in three medication errors out of 32 opportunities or a 9.37 percent (%) medication error rate. This affected two (#32, #56) of three residents observed during medication administration. The facility census was 47. Findings include: 1. Review of medical record for Resident #32 revealed admission date of 06/07/22. Medical diagnoses included but were not limited to diabetes mellitus, hypertension and peripheral vascular disease. The resident remains at the facility. Observation on 11/29/23 at 7:42 A.M. of Licensed Practical Nurse #6 during medication administration for Resident #32 revealed an order for Lisinopril (hypertension) five milligrams (mg). LPN #6 stated the Lisinopril medication was not available. Review revealed the medication was last ordered on 10/21/23. A second observation revealed during the administration of 25 units of Levemir (Long acting insulin), LPN #6 took the cap off 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, observation, staff interviews and review of manufacturer instructions, the facility failed to ensure a residents insulin pen was primed according to manufacturer guidelines resulting in a significant medication error. This affected one (#32) of three residents observed for medication administration. Facility census was 47. Findings include: Review of medical record for Resident #32 revealed admission date of 06/07/22. Medical diagnoses included but were not limited to diabetes mellitus and peripheral vascular disease. The resident remains at the facility. Review of Resident #32' quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He was independent for eating, toileting, transfers and bed mobility. He received seven injections of insulin during the seven day look back period. Observation on 11/29/23 at 7:42 A.M. of Licensed Practical Nurse (LPN) #6 for Resident #32 revealed during the administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of hospital medical records, observations, staff interview, review of manufactures instruction policy review and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure proper infection control procedures were followed. This affected two residents (#33 and #34) of three residents reviewed for infection control. Facility census was 47. Findings include: 1. Review of medical record for Resident #34 revealed admission date of 6/1/22. Medical diagnoses included but were not limited to encephalopathy, paranoid schizophrenia and diabetes mellitus type II. The resident remains in the facility. Observation on 11/29/23 at 8:49 A.M. of Licensed Practical Nurse (LPN) #11 of medication administration for Resident #34 revealed he was to receive two units of Novolog insulin. LPN #11 removed the Novolog vial from its box and withdrew two units of insulin without cleaning the hub with alcohol. LPN #11 then went to Resident #34's room with 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 record reviews, observations, staff interviews, and review of the facility policy, the facility failed to ensure the resident's oxygen tubing was clean and changed regularly and failed to ensure Resident #16 had a physician's order for the administration of oxygen. This affected two (Residents #16 and #41) of three residents reviewed for oxygen administration. The facility census was 41 residents. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 09/01/22 with diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, and chronic respiratory failure (CRF). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively impaired and required supervision with activities of daily living (ADLs). Review of the physician orders for Resident #41 dated 01/25/23 revealed an order to change oxygen tubing once weekly. The was also an order dated 11/30/22 to administer oxygen continuously at two liters per minute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, observations, staff interviews and policy review, the facility failed to ensure medications were securely stored and not left at bedside. Additionally, the facility failed to lock treatment carts. This affected one (#09) of three residents reviewed for medication storage and had the potential to affect four (#15, #27, #1 and #14) residents identified by the facility as cognitively impaired and independently mobile. Facility census was 41. Findings include: 1. Medical record review for Resident #09 revealed an admission on [DATE] with diagnoses including but not limited to metabolic encephalopathy, stroke, end stage renal disease, dependence on renal dialysis, seizures, adult failure to thrive, chronic respiratory failure, malnutrition, diabetes type two and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #09 revealed impaired cognition. Resident #09 requires extensive assistance from one staff member for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, policy reviews and review of the Center of Disease Control guidance, the facility failed to maintain appropriate infection control practices by ensuring staff properly sanitized/disinfected a blood glucose device (glucometer) after use for a resident and by ensuring staff did not did not contaminate medications during the medication preparation process. This affected one (#09) of three residents sampled for infection control practices and had the potential to affect three (#10, #01 and #02) additional residents identified by the facility with orders to monitor blood glucose levels using the same multi-user glucometer. Additionally, the facility failed to use a protective barrier between bed linen and clean wound supplies for wound dressing change. This affected one (#13) of three residents sampled for wound care. Facility census was 41. Finding include: 1. Medical record review for Resident #09 revealed an admission on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, staff interviews, and review of the facility policy, the facility failed to ensure proper storage of medications including ensuring that expired medications were not being used. This affected two of the four medication carts and one of one medication storage room located in the facility. This had the potential to affect eighteen residents due to expired medications and one other resident (#30) related to medication storage. The facility census was 56. Findings include: 1. Observations and interview on 12/06/22 from 11:30 A.M. to 12:00 P.M. of two facility medication carts and one medication storage room with Licensed Practical Nurse (LPN) #772 revealed outdated medications. The outdated medications found were Calcium 500 milligrams (mg) dated 11/22/22, Aspirin 325 mg 07/22/22, Claritin 10 mg dated 09/22/22, Naproxen 220 mg 11/22/22, and Magnesium 500 mg 08/22/22. LPN #772 confirmed the outdated medications including Calcium, Aspirin, Claritin, Naproxen, and Magnesium. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Self-Reported Incidents (SRI), and review of the facility policy, the facility failed to report an allegation of misappropriation to the State Survey Agency. This affected one (Resident #31) of one resident reviewed for abuse during the annual survey. The facility census was 56. Findings include: Review of the medical record for Resident #31 revealed an admission date of 02/06/19. Diagnoses included cerebral infarction, hemiplegia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/22, revealed Resident #31 had intact cognition. Resident #31 did not exhibit hallucinations, delusions, or rejection of care during the assessment reference dates. Review of the plan of care for Resident #31 revealed no documentation of any behaviors related to dishonesty or making up false information. Review of the progress notes dated 01/03/22 at 2:20 P.M. revealed Resident #31 continued to state people were taking his money. Resident #31 was advised by staff to secure his money in 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 record review, staff interview, and review of the facility policy, the facility failed to investigate an allegation of misappropriation. This affected one (Resident #31) of one resident reviewed for abuse during the annual survey. The facility census was 56. Findings include: Review of the medical record for Resident #31 revealed an admission date of 02/06/19. Diagnoses included cerebral infarction, hemiplegia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/22, revealed Resident #31 had intact cognition. Resident #31 did not exhibit hallucinations, delusions, or rejection of care during the assessment reference dates. Review of the plan of care for Resident #31 revealed no documentation of any behaviors related to dishonesty or making up false information. Review of the progress notes dated 01/03/22 at 2:20 P.M. revealed Resident #31 continued to state people were taking his money. Resident #31 was advised by staff to secure his money in a lock box or in the resident trust account. Resident #31 refused this suggestion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a comprehensive assessment of the resident's cognition and behavior on the Minimum Data Set (MDS) assessments. This affected three (#37, #38, and #47) of 22 residents reviewed for MDS assessments. The facility census was 56. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 04/07/15. Diagnoses included end-stage renal disease. Review of the quarterly MDS assessment for Resident #37 dated 11/11/22 revealed no documentation regarding the cognition of the resident. No brief interview for mental status (BIMS) score was completed for the resident. No mood or behaviors were assessed for the resident. Interview on 12/08/22 at 12:41 P.M. with MDS Nurse #298 confirmed the quarterly MDS assessment dated [DATE] for Resident #37 was not complete. MDS Nurse #298 added that the facility did not have consistent social services coverage at that time, and they were 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 and staff interview, the facility failed to have a discharge summary or recapitulation of stay for a resident. This affected one (Resident #307) of four residents reviewed for discharge. The facility census was 56. Findings include: Review of Resident #307's closed medical record revealed an admission date of 09/24/22. Diagnoses included acute and chronic respiratory failure, morbid obesity, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #307 had intact cognition. The discharge MDS assessment revealed Resident #307 was discharged to home on [DATE]. Further review Resident #307's closed medical record revealed no documented discharge summary or recapitulation of her stay. It was unclear what Resident #307's disposition was at discharge. Review of the progress notes revealed there was no documentation of Resident #307's discharge status. The last documentation was a nurse practitioner note dated 10/20/22 at 1:00 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based medical record review, staff interview, and review of the facility policy, the facility failed to complete urinary catheter care as physician ordered for a resident. This affected one (Resident #25) one resident reviewed for a urinary catheter. The facility identified two residents with urinary catheters. The facility census was 56. Findings include: Review of Resident #25's medical record revealed an admission date of 06/04/22. Diagnoses included urinary retention and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact, required extensive assistance with activities of daily living (ADLs), and had an indwelling urinary catheter. Review of the physician order dated 06/21/22, revealed an order to flush (irrigate) suprapubic catheter with 30 milliliters (ml) of normal saline (NS) every six hours and as needed (PRN). Review of the treatment administration records for December 2022 revealed flushing of Resident #25's suprapubic catheter was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to timely re-assess and address the resident's significant weight gain or weight loss. This affected two residents (#37 and #47) of four residents reviewed for nutrition. The facility census was 56. Findings include: 1. Review of the medical record of Resident #37 revealed an admission date of 04/07/15. Diagnoses included end-stage renal disease, dependence on dialysis, hypertension, and hypokalemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had an intact cognition and had no hallucinations, delusions, or rejection of care was noted. Resident #37 required supervision from staff for eating. No swallowing concerns or therapeutic diets were noted on the assessment. Review of the plan of care dated 11/12/22 revealed Resident #37 had a history of significant weight changes. Interventions included obtaining and monitoring weights, providing diet and fluids 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 and staff interview, the facility failed to ensure the resident's medical record was accurate. This affected one (Resident #20) of 22 residents reviewed for accuracy of the medical records. The facility census was 56. Findings include: Medical record review for Resident #20 revealed an admission date 03/25/22. Diagnoses included bipolar disorder and major depressive disorder. Review of the plan of care dated 03/25/22 revealed Resident #20 was at risk for drug related complications: related to psychotropic medication use antipsychotic. Interventions included to observe for drug related side effects (drowsiness, sedation, dizziness, lethargy, headache, insomnia, increased confusion, vertigo, dry mouth, tachycardia, blurred vision, seizures, abnormal tongue movement, abnormal jerking/twitching/writhing, tremors). Review of the physician orders dated 12/01/22 revealed an order to complete an Abnormal Involuntary Movement Scale (AIMS) assessment every three months while Resident #20 was on an antipsychotic. Review of the Treatment Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to provide or offer the COVID-19 vaccines to residents. This affected two (#2 and #48) of five residents reviewed for immunizations. The facility census was 56. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 03/04/22. Diagnoses included morbid obesity and history of pulmonary embolism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. Review of Resident #2's immunization list revealed one dose of a two dose COVID-19 vaccine was listed as being administered prior to admission on [DATE]. Further review of Resident #2's medical record revealed no documentation of a second dose of the COVID-19 vaccine being offered or administered. There was not any documentation of any refusals of the COVID-19 vaccine or any contraindications. During an interview on 12/08/22 at 10:20 A.M., the Director of 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 risk assessment, review of water temperature logs, observation, staff interview and review of facility policy and procedures the facility failed to ensure the laundry room maintain proper infection control measures. In addition the facility failed to ensure an effective Legionella monitoring program was in place. This had the potential to affect all 48 residents residing in the facility. Findings include: 1. On 12/03/19 at 4:40 P.M. an observation was made of the laundry room. The dirty side of the laundry room was observed to have racks of clean linens and personal laundry stored on the dirty side and the door was also observed to have clean Hoyer pads hanging on the door where the dirty barrels of cloths were dropped off at. During an interview on 12/03/19 at 4:42 P.M., the Administrator verified the laundry room had the clean linens stored on the dirty side of the laundry room where the washing machines and dirty laundry bins were located. He further verified it did not maintain proper infection control. Review of the facility policy and procedures for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the electronic medical record contained documentation of physician's orders for advanced directives for two Residents (#23 and #46) of three reviewed during the annual survey. The facility census was 48. Findings include: 1. Review of Resident #23's medical record revealed an admission date of 06/18/19 with medical diagnoses of muscle weakness, abnormalities of gait and mobility, lack of coordination, hypertension,, pressure ulcer of left buttock stage three, dysphagia oropharyngeal phase, presence of pacemaker, pressure ulcer of right buttock stage three, pressure ulcer of left buttock unstageable, type two diabetes mellitus, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23's cognition was severely impaired. Review of the hard chart for Resident #23 revealed a signed Do Not Resuscitate Comfort Care (DNR CC) advance directive. Review of the electronic medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, staff interview, and review of facility policy and procedures the facility failed to ensure a request for a demand bill was carried out appropriately to ensure a resident continued to receive Medicare Part A services as requested. This affected one (Resident #19) of three residents reviewed for beneficiary protection notification. The facility census was 48. Findings include: Review of the closed medical record for Resident #19 revealed an admission dated of 09/20/19 with diagnoses including chronic obstructive pulmonary disease, diabetes type two, hyperkalemia, hypothyroidism, schizophrenia, major depressive disorder, anxiety disorder, insomnia, essential hypertension, muscle weakness and lack of coordination. Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #19 was cognitively intact without any deficits. Review of notification of discharge from therapy dated 11/11/19 documented Resident #19's last days of skilled Physical Therapy (PT) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents and their responsible parties were provided with transfer discharge notices for residents hospitalization. This affected three Residents (#8, #23 and #46) of three reviewed for transfer discharge notices. The facility census was 48. Findings include: 1. Medical record review for Resident #8 revealed an admission date of 01/23/15. Medical diagnoses included acidosis, atrial fibrillation, schizophrenia, bradycardia, hypotension, hyperkalemia, type one diabetes mellitus, fracture of neck of right femur, atrial fibrillation, congestive heart failure, depression, acquired absence of right leg below knee, acute kidney failure, and opioid dependence. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8's cognition was intact. Further review of Resident #8's medical record revealed the resident received a bed hold letter on 08/11/19 but had not received a transfer discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were submitted within 14 days of completion to Center for Medicare & Medicare Services (CMS). This affected one (Resident #2) of one resident reviewed for resident assessments based on information submitted to CMS. The facility census was 48. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/17/19 with diagnoses including hemiplegia, chest pain, conversion disorder, hypertension, diabetes type two, major depressive disorder and chronic kidney disease. Review of the quarterly MDS assessment dated [DATE] documented the facility was identified as not being a Medicare or Medicaid certified facility and the assessment was never submitted/transmitted to CMS. Review of the quarterly MDS assessment dated [DATE] documented the facility was identified as not being a Medicare or Medicaid certified facility and the assessment was never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and resident interview and staff interview the facility failed to ensure care planning conferences were being held. This affected two Residents (#7 and #21) of four reviewed for care planning conferences. The facility census was 48. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 06/03/19 with diagnoses including dysphagia, muscle weakness, difficulty walking, acute stress reaction, functional urinary incontinence and cervical spinal cord injury unspecified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 was cognitively intact without any deficits. Review of nursing notes from 06/03/19 through 12/04/19 lacked any documentation of Resident #7 having any care conferences held. During an interview on 12/02/19 at 11:28 A.M., Resident #7 revealed he had not had any care planning conferences. During an interview on 12/04/19 at 1:04 P.M., Social Worker Designee #50 verified Resident #7 had not…

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

Based on medical record review, observation, and resident and staff interviews, the facility failed to ensure a physician ordered splint was implemented. This affected one (Resident #21) of one resident reviewed for limited range of motion (ROM). The facility census was 48. Findings include: Review of the medical record for Resident #21 revealed an admission date of 09/27/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, chronic obstructive pulmonary disease (COPD) and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/02/19, documented Resident #21 as having severe functional range of motion impairment to one side of her upper and lower extremity and had moderate impaired cognition. Review of physician order dated 08/06/19 revealed Resident #21 was to have a left wrist brace applied every shift and may remove for personal hygiene Review of the current comprehensive care plan dated 10/07/19 revealed Resident #21 did not have a care plan in place for her left hand brace 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of facility policy and procedure the facility failed to ensure medical care equipment was plugged into a proper electrical outlet. This affected one (Resident #15) resident during a random observation. In addition the facility failed to ensure smoking material was properly secure for a dependent resident. This affected one (Resident #8) out of two residents reviewed for smoking. The facility further failed to ensure fall interventions were in place to prevent a resident's fall. This affected one (Resident #37) out of three residents reviewed for falls. The facility census was 48. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 02/28/13. Medical diagnoses included heart failure, diffuse traumatic brain injury, anxiety, depression, bipolar, pulmonary fibrosis, persistent vegetative state, and anoxic brain damage. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents had proper diagnoses for medications and also failed to ensure blood draw orders had the correct reason. This affected one (Resident #8) of five residents reviewed for unnecessary medication. The facility census was 48. Findings include: Medical record review for Resident #8 revealed an admission date of 01/23/15. Medical diagnoses included acidosis, atrial fibrillation, schizophrenia, bradycardia, hypotension, hyperkalemia, type one diabetes mellitus, fracture of neck of right femur, atrial fibrillation, congestive heart failure, depression, acquired absence of right leg below knee, acute kidney failure, and opioid dependence. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8's cognition was intact. Review of Resident #8's physician orders revealed orders for Amiodarone (anti-arrhythmic)100 milligrams (mg) one tablet per day for other lack of coordination, Clopidigrel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and facility policy review, the facility failed to ensure one of five medication carts were locked and secure. This had the potential to affect two Resident's (#44 and #45) the facility identified as independently mobile and cognitively impaired. The facility census was 48. Findings include: 1. Review of the medical record of Resident #44 revealed an admission date of 05/12/18. Medical diagnoses included psychosis, depression, and chronic pain. Review of Resident #44's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was impaired and the resident was independently mobile. 2. Review of the medical record of Resident #45 revealed an admission date of 01/13/15. Medical diagnoses included dementia, hypertension, gout and type two diabetes mellitus. Review of Resident #45's quarterly MDS assessment dated [DATE] revealed the resident's cognition was impaired and the resident was independently mobile. Random…

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