Twinsburg Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, family, staff and certified nurse practitioner (CNP) interviews, record review, and review of the facility policy, the facility failed to timely notify the physician/CNP when physician orders were not completed and pharmacy irregularities on a antibiotic and notify a resident's representative of an incident and a room change involving the resident. This affected two (Residents #1 and #20) of three residents reviewed for notification of change. The facility census was 70. 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment.Review of the physician's orders revealed an order dated 03/31/25 to straight catheterize every six hours for urinary retention four times a day. The procedure 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 observation, interview, record review, and review of the facility policy, the facility failed to ensure wound care was completed as per the physician orders for one resident, Resident #57 of three residents reviewed for wound care. The facility census was 70.Findings include:Record review for Resident #57 revealed an admission date of 10/23/23. Diagnoses included multiple sclerosis, sepsis, chronic osteomyelitis, colostomy, neuromuscular disfunction of the bladder, pressure ulcer stage IV (Full thickness loss with exposed bone, tendon or muscle), and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57 had impairment on one side of the upper extremity and both sides of the lower. Resident #57 was dependent on staff for all activities of daily living (ADL). Resident #57 was at risk for pressure ulcers, had one stage IV pressure ulcer and one unstageable pressure ulcer (slough and/or eschar: known but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and pharmacy, the facility failed timely respond and act upon the pharmacy's notification regarding irregularity with a new order to start an antibiotic. This affected one (#20) of one resident reviewed for pharmacy services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Interview on 08/06/25 at 3:40 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 on record review and interviews with staff, the facility failed to timely obtain a urinalysis ordered by the physician/certified nurse practitioner (CNP). This affected one (#20) of one resident reviewed for laboratory services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) during stay, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. The assessment revealed Resident #20 required supervision or touch assistance with toileting hygiene. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment. On 08/04/25 an order was obtained to remove indwelling catheter today (08/04/25) and straight catheterize every four to six hours. On 08/07/25 there was an order by Certified Nurse Practitioner (CNP) #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure staff wore personal protective equipment (PPE) for a resident on Enhanced Barrier Protection (EBP). This affected one (#20) of one resident reviewed for infection control. The facility census was 70. Findings include: Record review for Resident #20 revealed an admission date of 07/20/24. Diagnoses included Parkinson's disease and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter. Review of the physician orders for Resident #20 revealed an order dated 03/31/25 to straight catheterize every six hours or urinary retention four times a day for urinary retention; an order dated 08/01/25 for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth 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 record review and interview, the facility failed to ensure adequate supervision was provided to prevent Resident #7 from leaving the facility property unsupervised. This affected one (Resident #7) of four residents reviewed for leave of absence (LOA). The facility census was 70. Findings include: Review of the medical record for Resident #7 revealed an admission date of 06/09/25. Diagnoses included paranoid personality disorder, bipolar disorder, and schizophrenia. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 06/16/25, revealed Resident #7 had moderately impaired cognition. The assessment did not identify the resident to have behaviors, including the behavior of wandering. The resident was independent with ambulation. Review of the physician's orders for June 2025 identified orders for Wanderguard (a bracelet that helps prevents residents with cognitive impairment from leaving the facility unsupervised and potentially getting lost or injured); Provide a reminder to resident 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 observation, interview, review of the manufacturer's instructions for use of Insulin Glargine - yfgn and review of facility policy, the facility failed to ensure medications were administered according to physician's orders for Residents #22, #38, and #54. This affected three residents (#22, #38 and #54) of three residents reviewed for insulin administration and had the potential to affect ten additional residents (#2, #3, #5, #12, #16, #25, #26, #34, #44 and #45) identified by the facility with physician's orders for insulin. The facility census was 65. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 01/13/25 and a re-entry date of 01/18/25. Admitting diagnoses included type two diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure (CHF), stage three chronic kidney disease, morbid obesity, gastroesophageal reflux disease (GERD), hyperglycemia, obstructive sleep apnea, chronic pain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 electronic medical records (EMR), hard charts and binders (utilized during transition of EMR) and interviews with staff, the facility failed to maintain complete, accurate, and readily accessible records for Residents #6, #17, #22, #51 and #53. This affected five (#6, #17, #22, #51 and #53) of seven resident records reviewed for complete and accurate medical records. The facility census was 65. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 3/01/24 with a readmission date of 07/05/24. Diagnoses included dementia with agitation, chronic kidney disease, and history of falls. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively impaired. Review of the care plan initiated on 03/29/24 revealed a problem for resistive behaviors indicating Resident #6 became easily agitated. Review of a progress note dated 12/29/24 revealed Resident #6 was combative prior to a fall; however, it did not specify 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, interview and review of the facility policy, the facility failed to ensure Resident #22's resident representative was informed of a medication change and a fall. This affected one resident (#22) of three residents reviewed for changes in condition. The facility census was 65. Findings include: Review of the medical record for Resident #22 revealed he was admitted to the facility on [DATE] with diagnoses including fracture of the nasal bone with routine healing, fracture of the distal phalanx of the right little finger with routine healing, emphysema, encounter after fall, repeated falls, severe protein-calorie malnutrition, muscle weakness, laceration of unspecified cheek and temporomandibular area, ischemic cardiomyopathy, presence of a cardiac pacemaker, and type two diabetes mellitus. Review of the resident profile and contact information revealed the daughter of Resident #22 was listed as his emergency contact and responsible party. Review of the admission Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and facility policy review, the facility failed to implement baseline care plans within 48 hours after admission for Resident #22, Resident #38 and Resident #62. This affected three residents (#22, #38, and #62) of three residents reviewed for baseline care plans. The facility census was 65. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 12/18/24 with diagnoses including fracture of nasal bones, displaced fracture of distal phalanx of the right little finger, diabetes, and emphysema. Initial review of the of the electronic medical record (EMR) and the hard chart on 01/28/25 revealed there was no baseline care plan in place. Review of the binders containing paper documentation from 12/22/24 through 12/31/24 provided by the Director of Nursing (DON) revealed there was no baseline care plan in place. A subsequent review of the EMR (days after survey entrance) revealed a written baseline care plan dated 12/19/24 was uploaded into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and review of facility policy the facility failed to ensure a comprehensive care plan was developed and implemented for Resident #22. This affected one resident (#22) of three residents reviewed for care plans. The facility census was 65. Findings include: Review of the medical record for Resident #22 revealed he was admitted to the facility on [DATE] with diagnoses including fracture of the nasal bone with routine healing, fracture of the distal phalanx of the right little finger with routine healing, emphysema, encounter after fall, repeated falls, severe protein-calorie malnutrition, muscle weakness, laceration of unspecified cheek and temporomandibular area, ischemic cardiomyopathy, and presence of a cardiac pacemaker, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 12/29/24 revealed Resident #22 had intact cognition. Further review of the MDS revealed Resident #22 had sustained falls within one month 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, interview and review of the facility policy, the facility failed to ensure Resident #22's fall was thoroughly investigated and failed to ensure fall interventions were in place to prevent a subsequent fall. This affected one resident (#22) of three residents reviewed for falls. The facility census was 65. Findings include: Review of the medical record for Resident #22 revealed he was admitted to the facility on [DATE] with diagnoses including fracture of the nasal bone with routine healing, fracture of the distal phalanx of the right little finger with routine healing, emphysema, encounter after fall, repeated falls, severe protein-calorie malnutrition, muscle weakness, laceration of unspecified cheek and temporomandibular area, ischemic cardiomyopathy, and presence of a cardiac pacemaker, and type two diabetes mellitus. Review of the baseline care plan completed on 12/19/24 revealed Resident #22 was a fall risk and was admitted for a previous fall. Further review of the baseline…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, manufacturer's instructions for use of Insulin Glargine - yfgn and review of the facility policy, the facility failed to ensure a medication error rate of less than five percent. This affected three residents (#4, #38, and #54) of five residents observed for medication administration and yielded a 13.79 percent medication error rate. The facility census was 65. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 01/13/25 and a re-entry date of 01/18/25. Admitting diagnoses included type two diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure (CHF), stage three chronic kidney disease, morbid obesity, gastroesophageal reflux disease (GERD), hyperglycemia, obstructive sleep apnea, chronic pain, hypothyroidism, and long-term use of insulin. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 01/23/25 revealed the Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, review of the facility policy and review of the Centers for Disease Control and Prevention (CDC) website's Considerations for Blood Glucose Monitoring and Insulin Administration summary of recommendations for blood glucose monitoring, the facility failed to properly clean and disinfect the blood glucose monitor (BGM) between resident use. This affected one resident (Resident #54) of five residents observed during medication administration and had the potential to affect three additional residents (#5, #12 and #38) who receive blood sugar monitoring in the 200 Mid Hall. The facility census was 65. Findings include: Review of the medical record for Resident #54 revealed he was admitted on [DATE] with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, unspecified severe dementia with agitation, epilepsy, moderate protein-calorie malnutrition, anxiety disorder, mental disorder not otherwise specified, anemia, hyperlipidemia, alcohol dependence (in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a video recording, staff interview, record review, and review of the facility policy, the facility failed to treat a resident with respect and dignity. This affected one (Resident #72) of three residents reviewed for dignity and respect. The facility census was 69. Findings include: Record review for Resident #72 revealed an admission date of 08/02/24 and a discharge date of 11/02/24. Diagnoses included dementia, diaphragmatic hernia, and muscle weakness. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was severely cognitively impaired. Resident #72 had clear speech, was able to understand others and was able to make self-understood. Resident #72 had impairment on both sides of lower extremities, was dependent on staff for toileting, bed mobility, moving from a sitting to standing position, and transfers. Review of the video footage provided by the family, dated 10/11/24 at 9:30 A.M., revealed the family had a video camera in Resident #72'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 review of a video recording, staff interviews, record review, and review of the facility policy, the facility failed to safely transfer a resident per the care plan, failed to timely assess the resident status post fall, and document the fall in the medical record. This affected one (Resident #72) of three residents reviewed for falls. The facility census was 69. Findings include: Record review for Resident #72 revealed an admission date of 08/02/24 and a discharge date of 11/02/24. Diagnoses included dementia, calculous of the gallbladder, diaphragmatic hernia, and muscle weakness. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was severely cognitively impaired. Resident #72 had impairment on both sides of lower extremities and was dependent on staff for bed mobility, moving from a sitting to standing position, and transferring. Review of the care plan dated 08/05/24 revealed Resident #72 was a fall risk characterized by impaired balance and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy the facility failed to ensure physician orders were followed to obtain blood pressure reading prior to medication administration for Resident #70. This affected one resident (#70) of four residents reviewed for medication administration. The facility census was 71. Findings include: Review of the medical record for Resident #70 revealed an admission date of 06/21/23. Medical diagnoses included chronic obstructive pulmonary disease, paraplegia, anxiety, major depressive disease, essential hypertension, neuromuscular dysfunction of bladder, and personal history of urinary tract infection. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 required setup or clean-up assistance with eating and oral hygiene, partial to moderate assistance with toileting, upper body dressing, and personal hygiene, substantial to maximal assistance with shower/bathing and lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, review of the medical record and facility policy the facility failed to ensure timely incontinence care was provided for Resident #70. This affected one resident (#70) of three residents reviewed for incontinence care. The facility census was 71. Findings include: Review of the medical record for Resident #70 revealed an admission date of 06/21/23. Medical diagnoses included chronic obstructive pulmonary disease, paraplegia, anxiety, major depressive disease, essential hypertension, neuromuscular dysfunction of bladder, and personal history of urinary tract infection. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 required setup or clean-up assistance with eating and oral hygiene, partial to moderate assistance with toileting, upper body dressing, and personal hygiene, substantial to maximal assistance with shower/bathing and lower body dressing and was dependent on staff for putting on/taking off…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to ensure Resident #28's physician, power-of-attorney (POA) and hospice service were notified in a reasonable timely manner for a change of condition, and failed to ensure Resident #28's POA was notified of new physician's orders as well as radiology results. This affected one (Resident #28) of three residents reviewed for a change in condition and notification. The facility census was 78. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/01/16 with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure and dementia. She was admitted to hospice on 05/22/24. Resident #28's son was listed as her POA. Review of the nursing progress note dated 06/18/24 at 6:55 P.M. revealed Resident #28 had a new order for an X-ray to her right hip. There was no documentation of the POA being updated on the new order or the results of the X-ray. Review of the nursing progress note dated 06/22/24 at…

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

Based on record review and interview, the facility failed to ensure Resident #28's pain medications were administered as ordered. This affected one (Resident #28) of five residents reviewed for medication administration. The facility census was 78. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/01/16 with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, dementia and osteoarthritis. Review of Resident #28's physician's orders for June 2024 and July 2024 revealed she had an order for Tramadol 50 milligrams (mg) three times a day for pain dated 06/14/24. Review of the Medication Administration Record (MAR) for June 2024 and July 2024 revealed Resident #28 received her Tramadol as ordered. Review of Resident #28's narcotic count sheet dated from 06/24/24 through 07/04/24 for Tramadol 50 mg revealed she received only one dose on 06/25/24, two doses on 06/30/24 and two doses on 07/01/24. Resident #28 was to receive three doses each day per the physician's order. Interview on 07/09/24 at 1:40 P.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.

Based on record review and interviews, the facility failed to ensure documentation in the medical record was complete and accurate. This affected two (Residents #28 and #55) of eight residents reviewed for documentation of medication and treatment administration. The facility census was 78. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 11/01/16 with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, dementia and osteoarthritis. Review of Resident #28's physician's orders for June 2024 and July 2024 revealed she had an order for Tramadol 50 milligrams (mg) three times a day for pain dated 06/14/24; treatment to her right fifth toe every night shift dated 07/04/24; treatment to her right heel with applying skin prep and covering with abdominal (ABD) pad every night shift dated 07/04/24; treatment to her bilateral buttocks/coccyx with cleansing with soap and water, patting dry and applying Zinc every shift and as needed dated 07/06/24; dycem under the cushion of her wheel chair for safety every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure medications were administered without error. This affected two residents (#32 and #79) of four residents observed during 29 medication opportunities with seven medication errors. The medication administration error rate was 24.13 %. The facility census was 80. Findings include: 1. Resident #32 was admitted [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, high blood pressure, pulmonary embolism, constipation, and hyperlipidemia. A review of Resident #32's physician orders dated 03/02/24 indicated to administer ethylene glycol 17 grams once a day for constipation. (The bottle cap is a measuring cap marked to contain 17 grams of powder when filled to the indicated line inside the cap). An observation of LPN #82 on 05/14/24 at 8:30 A.M. revealed an inaccurate dose of ethylene glycol was administered to Resident #32. LPN #82 obtained a medication cup and measured 17 milliliters (ml) 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 and interview the facility failed to ensure staff documented Resident #32's shower/bath accurately. This affected one out of three residents reviewed for activity of daily living needs. The facility census was 80. Findings include: Resident #32 was admitted [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, high blood pressure, pulmonary embolism, constipation, and hyperlipidemia. A review of Resident #32's plan of care dated 11/09/23 indicated Resident #32 preferred to receive a shower or bed bath in the evening or sometime during the morning. A review of the facility shower schedule indicated Resident #32 should receive a shower on Tuesdays and Saturdays during the night shift hours. A review of Resident #32's Minimum Data Set (MDS) assessment dated [DATE] indicated a shower/bath was not attempted due to medical condition or safety concerns. The MDS assessment indicated she had impairment of both upper/lower body extremities and needed substantial/maximal staff'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 observation and interview the facility failed to ensure staff washed their hands appropriately to prevent possible cross contamination of germs during Resident #32's and Resident #79's medication administration, failed to ensure staff wore appropriate personal protective equipment (ppe) prior to administering insulin subcutaneously and eye drops to Resident #79, and failed to ensure Resident #79's eye drops were not contaminated prior to administering the eye drops to Resident #79. This affected two out of four residents observed for medication administration. The facility census was 80. Findings include: 1. Resident #32 was admitted [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, high blood pressure, pulmonary embolism, constipation, and hyperlipidemia. A review of Resident #32's physician orders dated 03/02/24 indicated to administer ethylene glycol 17 grams once a day for constipation. An observation of Licensed Practical Nurse (LPN) #82 revealed preparation to administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review the facility failed to serve foods in a sanitary manner to prevent contamination. This had the potential to affect all 83 residents who received food from the kitchen, except Residents #37, #59, and #387 who had orders for nothing-by-mouth (NPO). The facility census was 86. Findings include: On 03/20/24 from 4:56 P.M. to 6:03 P.M., observation of the dinner tray line revealed Dietary Manager (DM) #303 dropped the entire serving scoop in the pan of chicken and dumplings while serving. DM #303 then removed the scoop from the chicken and dumplings with his gloved hand, gave the scoop a shake to remove excess sauce from the handle, and continued serving the meal without removing or replacing any foods or utensils on the food line. This was verified by DM #303 at the time of observation. Review of the undated facility policy titled Food Preparation and Storage not indicated staff would handle utensils in a way to avoid touching any surfaces that would come into contact with food.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to assure staff were competent and compliant with medication administration documentation, physician notification, and use of a glucometer. This affected four residents (#390, #17, #45, and #64) of six residents reviewed during medication administration. The facility census was 86. Findings include: 1. Record review for Resident #390 revealed an admission date of 03/15/24. Diagnosis included encephalopathy. Review of the admission assessment dated [DATE] completed by Licensed Practical Nurse (LPN) #308 revealed Resident #390 had short- and long-term memory problems. Record review of the physician orders for Resident #390 revealed an order dated 03/15/24 for Valacyclovir (antiviral) give one gram by mouth one time a day for virus. Observation of medication administration on 03/20/24 at 8:25 A.M. with Registered Nurse (RN) #309 for Resident #390 revealed Valacyclovir one gram was not available for administration. RN #309…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, the facility failed to provide medication per the physician order for four residents, Resident #7, #390, #17, and #64 of six residents reviewed for medication administration. The facility census was 86. Findings include: 1. Record review for Resident #7 revealed an admission date of 01/18/24. Diagnosis included pneumonia, anxiety, and other symptoms involving the musculoskeletal system. Review of the physician orders for March 2024 revealed an order for benadryl allergy oral tablet 25 milligrams (mg) by mouth every six hours for itching. Observation of medication administration on 03/19/24 at 11:26 A.M. with Licensed Practical Nurse (LPN) #311 administer medications to Resident #7 revealed LPN #311 placed benadryl allergy oral tablet 50 mg's in the medication cup to administer to Resident #7. LPN #311 picked up the cup for administration when the surveyor clarified the dosage. LPN #311 confirmed the dose she placed in the cup was 50 mg. LPN #311 confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review, the facility failed to ensure medications for Residents #66, #384, and #389 were properly prepared for administration and failed to ensure medications for Resident #238 were stored as required. This affected four residents (#66, #384, #389, and #238) of nine residents reviewed medication storage. The facility census was 86. Findings include: 1. Observation on 03/19/24 at 11:11 A.M. revealed Licensed Practical Nurse (LPN) #311 had pre-poured medications for Residents #66, #384, and #389 in individual medication cups. LPN #311 stacked the three medication cups on top each other in one hand and carried three cups of water in the other. Observation revealed LPN #311 walked down the hall, entered each of the three resident's rooms one at a time and administered one medication cup to each resident. LPN #311 confirmed she pre-poured Residents #66, #384, and #389's medications. Review of the facility policy titled Medication Administration-General Guidelines, dated November 2021, revealed medications are…

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

Based on record review and interview, the facility failed to ensure residents had advanced directives in their medical records. This affected two residents (#53 and #396) of two reviewed for advance directives. The facility census was 86. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 02/15/24 with diagnoses of chronic obstructive pulmonary disease, urinary tract infection, anxiety, and dementia. Review of the physician's orders, both in the electronic medical record and paper medical record, for March 2024 identified no advanced directives were ordered for Resident #53. On 03/19/24 at 11:58 A.M., interview with the Director of Nursing confirmed Resident #53 did not have any orders for advanced directives in either the electronic or paper medical records. 2. Review of the medical record for Resident #396 revealed an admission date of 03/18/24 with diagnoses including syncope and collapse, open wound of the lower left leg, hyperlipidemia, hypothyroidism, transient ischemic attack and cerebral infarction, hypertension, depression,…

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

Based on record review and interview the facility failed to provide evidence they notified the resident or representative of non-coverage in writing on the Notice of Medicare Non-Coverage (NOMNC) for Residents #9, #28, and #239. This affected three residents (#9, #28, and #239) of three residents reviewed for liability notices. The facility census was 86. Findings include: Review of the NOMNC for Resident #9 revealed the last covered day of Medicare was 02/26/24. Telephone notification was made on 02/22/24 at 4:30 P.M. and the letter was signed by the Director of Nursing. There was no signature from the resident or the responsible party. Review of the NOMNC for Resident #28 revealed the last covered day of Medicare was 01/17/24. Telephone notification was made on 01/15/24, no specified time, and was signed by Social Service Designee (SSD) #302. There was no signature from the resident or the responsible party. Review of the NOMNC for Resident #239 revealed the last covered day of Medicare was 02/19/24. Telephone notification was made on 02/14/24 and was signed by SSD #302. There 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 interview, record review, and review of the facility policy, the facility failed to have a quarterly care conference with Resident #66 and his family. This affected one resident (#66) of three residents reviewed for care plan meetings. The facility census was 86. Findings include: Record review for Resident #66 revealed an admission date of date 07/25/23. Diagnoses included pressure ulcer of sacral region, post laminectomy syndrome, type two diabetes mellitus with diabetic neuropathy and peripheral angiopathy, obstructive sleep apnea, chronic embolism, and thrombosis of deep veins of right and left proximal lower extremities, acquired absence of left great toe and right leg below the knee, muscle weakness and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #66 revealed Resident #66 required substantial/maximum assistance with toileting and partial moderate assistance with personal hygiene. Review of the weekly wound note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, record review, and review of the facility policies, the facility failed to assist Resident #66 with showers or bed baths as preferred and failed to provide timely incontinence care to Resident #390. This affected two residents (#66 and #390) of five residents reviewed for activities of daily living. The facility census was 86. Findings include: 1. Record review for Resident #66 revealed an admission date of 07/25/23. Diagnoses included pressure ulcer of sacral region, diabetes mellitus, and post laminectomy syndrome. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 required assistance with bathing. Review of the plan of care dated 10/31/23 for Resident #66 revealed preferences were identified. The resident preferred to choose how often to bathe. Resident #66 was satisfied with the current schedule. Review of the shower schedule for Resident #66 revealed showers were scheduled for Wednesdays and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and facility policy review the facility failed to serve meals at an appropriate temperature. This affected one resident (#49) of five residents observed for meals. The facility census was 86. Findings include: Review of the medical record for Resident #49 revealed an admission date of 02/23/24. Diagnoses included fusion of spine, cervical region, quadriplegia, cervical five through seven, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had intact cognition. Resident #49 was dependent for activities of daily living, including feeding. Observations on 03/19/24 at 5:19 P.M., State Tested Nursing Assistant (STNA) #300 delivered Resident #49's dinner tray. The meal consisted of stuffed cabbage, mashed potatoes, and green beans. Resident #49's main complaint during the survey was that his food was always cold. Resident #49 agreed to having temperatures of his food checked. 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, record review, interview, and facility policy review the facility failed to follow Resident #396's diet orders. This affected one resident (#396) of three residents reviewed for nutrition. The facility census was 86. Findings include: Review of the medical record for Resident #396 revealed an admission date of 03/18/24 with diagnoses including syncope and collapse, open wound of the lower left leg, hyperlipidemia, hypothyroidism, transient ischemic attack and cerebral infarction, hypertension, depression, osteoarthritis, insomnia, and glaucoma. Review of the physician's orders for March 2024 identified orders for a gluten free diet with mechanical soft texture. Review of the nutrition care plan, dated 03/20/24, revealed Resident #396 had altered nutritional status related to gluten and lactose intolerance, wound, history of edema, hypertension, transient ischemic attack, osteoarthritis, and depression. Interventions included alert dietitian if consumption is poor for more than 72 hours, diet provided per dietitian recommendation and physician's orders,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, record review, and review of the facility policy the facility failed to maintain infection control practices and encourage fluids for Resident #66. This affected one resident (#66) of three residents reviewed for infection control. The facility census was 86. Findings include: Record review for Resident #66 revealed an admission date of 07/25/23. Diagnosis included neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 had an indwelling Foley catheter. Review of the care plan dated 07/28/23 revealed Resident #66 was at risk for infection and or trauma related to the use of a Foley catheter, neurogenic bladder. Interventions included Foley catheter care every shift. Interview on 03/18/24 at 7:16 P.M. with Resident #66 revealed staff were not providing routine Foley catheter care. Observation of the catheter bag revealed Resident #66's urine was dark yellow. Resident…

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

Based on observation, menu extension review and interview, the facility failed to follow the menu. This had the potential to affect all residents who received meals from the kitchen except Residents #18, #26 and #50 who were ordered nothing-by-mouth (NPO). The census was 82. Findings include: Review of the Menu Extension dated 02/20/24 revealed ½ cup of peppers and onions to be served for residents ordered a regular and mechanical soft diet, combined three ounces of pureed beef /cheese with two ounces of gravy and two ounces of pureed bread for resident's ordered a pureed diet, ½ cup of pureed peppers and onions for residents ordered a pureed diet, and ½ cup of peaches (instead of Jello) for residents who were ordered mildly, moderately, or extensively thickened liquids. Observation on 02/20/24 at 4:38 P.M. revealed Dietary Manager (DM) #1 and Dietary Aide (DA) #5 beginning to serve food for dinner from the steam table in the kitchen. DM #1 was using unmeasured tongs to serve the peppers and onions which were placed on top of the beef for the Philly cheese beef sandwich. Interview,…

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

Based on observation, policy review, diet order report review, and interview the facility failed to ensure meals were served at a palatable temperature. This affected five residents (Residents #29, #67, #51 and one anonymous resident) and had the potential to affect all residents who received meals from the kitchen except Residents #18, #26 and #50 who were ordered nothing-by-mouth (NPO). The census was 82. Findings include: Interview on 02/20/24 at 3:13 P.M. with Resident #29 revealed she preferred to eat meals in her room and hot food was served cold. Interview on 02/20/24 at 3:55 P.M. with a resident who requested to remain anonymous revealed hot food was served cold. Observation on 02/20/24 at 4:15 P.M. revealed Dietary Manager (DM) #1 was taking food temperatures for dinner from the steam table in the kitchen. The Philly steak beef was 144.1 degrees Fahrenheit (F) and French fries were 152 degrees F. At 5:00 P.M. a test tray was placed on the meal cart. At 5:05 P.M. the meal cart was delivered to the low 200's hall and State Tested Nurse Aide (STNA) #4 and Registered Nurse (RN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, menu extension review, diet order report review and interview, the facility failed to ensure Resident #8 was served nectar-thickened liquids according to the physician order. This affected one resident (Resident #8) and had the potential to affect two additional residents (Residents #65 and #82) who were ordered thickened liquids. The census was 82. Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/27/22 with diagnoses of malignant neoplasm of the brain, acute and chronic respiratory failure with hypoxia, altered mental status, and dysphagia. Review of the February 2024 physician orders revealed Resident #8 was ordered a mechanical soft diet with nectar-thickened liquids. The order began on 01/05/24. Review of the nutrition progress note dated 02/05/24 revealed speech therapy (ST) updated the author of the progress note that she recommended a new Modified Barium Swallow (MBS) for Resident #8 to confirm need for thickened liquids. The ST was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure fall prevention interventions were implemented for Resident #14. This affected one resident (Resident #14) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical records for Resident #14 revealed an admission date of 01/09/19 with diagnoses including hemiplegia, cerebral infarction, chronic kidney disease, type two diabetes, aphasia and gastroparesis. Review of the Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed Resident #14 had a Behavior Interview Mental Score ( BIMS) of 10 revealing moderate cognitive impairment. Resident #14 needed two-person assistance for bed mobility, two-person assistance for transfers, and needed set up for eating. Review of the Fall Risk assessment dated [DATE] revealed a score of 17 indicating Resident #14 was at high risk for falls. Review of Plan of Care initiated 12/08/22 revealed a goal to minimize risk for falls. Interventions included…

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

Based on observation, interview, and facility policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 71 out of 73 residents who ate meals from the facility's kitchen. Resident #43 and #45 were identified as receiving nothing by mouth. The facility census was 73. Findings Include: Observation of the tray line on 11/02/23 from 11:50 A.M. through 12:50 P.M. revealed the orange chicken was 150 degrees Fahrenheit (F) and the egg roll was 141 degrees (F). Completion of a test tray and interview on 11/02/23 at 1:00 P.M. with Registered Dietitian, Licensed Dietitian (RD, LD) #280 revealed the orange chicken was 107 degrees F, the egg rolls were 116 degrees F, Lo Mein noodles were 121 degrees F, and the cold drink was 57 degrees F. The orange chicken, egg rolls and Lo Mein noodles were lukewarm and unsavory. RD, LD #280 verified the food temperatures did not meet temperature guidelines and indicated the reason was the excessive amount of time if took to plate the meals during tray line. Interview on 11/02/23 at 2:33 P.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.

Based on observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected 85 residents receiving meals from the kitchen as three residents (Residents #16, #77 and #89) were ordered nothing-by-mouth. The facility census was 88 residents. Findings include: Review of the spreadsheet for Week Two, Day 11 corresponding to 04/06/22 revealed a lunch meal consisting of chicken paprikash, mashed potatoes, gravy, brussels sprouts, bread with margarine, pudding and beverage. Portions for the meal included three ounces chicken paprikash; four ounces of mashed potatoes; four ounces of Brussels sprouts; one slice of bread; four ounces pudding and beverage of choice. The menu also crossed over to mechanical soft and pureed consistencies. Observations on 04/06/22 starting at 11:36 A.M. revealed [NAME] #400 was serving the meal. Utensils in use at the time of service included a three ounce spoodle for Brussels sprouts, four ounce spoodle for pork cubes and chicken paprikash, #8-scoop of mashed potatoes, two ounce ladle for both gravies, three ounce…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and menu spreadsheet review, the facility failed to serve palatable meals at appetizing temperatures. This affected 85 residents receiving meals from the kitchen as three residents (Residents #16, #77 and #89) received nothing-by-mouth. The facility census was 88 residents. Findings include: Review of the spreadsheet for Week Two, Day 11 corresponding to 04/06/22 revealed a lunch meal consisting of chicken paprikash, mashed potatoes, gravy, brussels sprouts, bread with margarine, pudding and beverage. Portions for the meal included three ounces chicken paprikash; four ounces of mashed potatoes; four ounces of Brussels sprouts; one slice of bread; four ounces pudding and beverage of choice. Observations on 04/06/22 starting at 11:36 A.M. revealed [NAME] #400 was serving the meal. Temperatures of the foods on the steamwell were taken with the facility's self-calibrating thermometer and were as follows: chicken paprikash, 146 degrees Fahrenheit (F); pork cubes, 170 degrees F; mashed potatoes, 156 degrees F; Brussels sprouts, 145 degrees F; hot dog, 175…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to ensure medications in the medication storage room were not expired. This had the potential to affect all 69 residents residing on the second floor. The facility census was 88. Findings Include: Observation on [DATE] at 4:43 P.M. of the medication storage room on the second floor revealed six bottles of multivitamins with an expiration date of 01/2022, four bottles of enteric coated aspirin 81 milligram (mg) with an expiration date of 01/2022, and two bottles of Enulose 10 mg per 15 milliliters (ml) with an expiration date of 12/2021 Interview on [DATE] at 4:43 P.M. with Registered Nurse (RN) #419 verified the above observations.

Based on observation and interview the facility failed to clean the glucometer after testing the blood sugar of diabetic residents. This affected five residents (Residents #12, #25, #26, #41, and #51) of 17 residents receiving medications from the medication cart. The facility census was 88. Findings Include: Review of the medical record for Residents #12, #25, #26, #41, and #51 revealed all five residents were insulin dependent diabetics. Observation on 04/06/22 at 8:47 A.M. revealed Registered Nurse (RN) #409 entered Resident #25's room to check her blood sugar. After obtaining the blood sugar RN #409 returned to the medication cart and placed the glucometer (an instrument used to determine a resident's blood sugar) on top of the medication cart. RN #409 then administered Resident #25's insulin and continued down the hall to administer medications to the other 17 residents residing on the hall. Interview with RN #409 on 04/05/22 at 8:55 A.M. revealed after use the glucometer was to be cleaned with bleach wipes and left to dry. RN #409 confirmed she did not clean the glucometer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and medical record review, the facility failed to develop and implement a dental plan of care for Resident #103 and failed to develop a plan of care related to safe positioning for Resident #15. This affected two of four residents reviewed for care plans. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 04/13/17 and a readmission date of 02/07/18. Diagnoses included malignant neoplasm of prostate (cancer), obstructive and reflux uropathy (a blockage in the urinary tract), morbid obesity, secondary unspecified malignant neoplasm of intrapelvic lymph nodes, essential primary hypertension, atherosclerotic heart disease, chronic diastolic heart failure, type 2 diabetes, schizophrenia, and other recurrent depressive disorders. Review of the care plan dated 02/10/22 revealed the care plan did not address Resident #103's poor oral health and need for teeth extraction for denture placement. Review of the social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, record review, and policy review the facility failed to ensure neurological checks were completed for Resident #62 post fall. This affected one of five residents reviewed for falls. The facility census was 88. Findings Include: Review of Resident #62's medical record revealed an admission date of 02/28/22 and diagnoses including heart failure, sarcoidosis, malignant neoplasm of lung, syncope and collapse, transient cerebral ischemic attack, dysphagia, cognitive communication deficit, cardiac arrest, elliptic seizures and mild-protein calorie malnutrition. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively impaired, had inattention, disorganized thinking and altered level of consciousness. Resident #62 required extensive assistance of two staff for bed mobility, was totally dependent on one staff for eating, required the extensive assistance of two staff for toileting, and required the extensive assistance of two staff for personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure fall interventions were in place for Resident #15. This affected one of five residents reviewed for falls. The facility census was 88. Findings Include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, right knee contracture, arthritis, high blood pressure, and depression. Review of the resident's care plans revealed she was at risk for falls due to impaired mobility, impaired balance, and a history of falls. Interventions to prevent falls included to use body pillows in bed and therapy evaluation and treatment per orders. Further review of the medical record revealed on 09/04/21 at 10:31 A.M. Resident #15 had a fall. Review of the fall investigation revealed Resident #15 was found on the floor after staff heard what sounded like a tray falling on the floor. State Tested Nursing Assistant (STNA) #415 went to investigate 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 interview and medical record review, the facility failed to ensure Resident #55's medications were reviewed monthly by a licensed pharmacist. This affected one of four residents reviewed for unnecessary medications. The facility census was 88. Findings include: Review of the medical record for Resident #55 revealed an admission date of 09/01/21 and a readmission date of 10/13/21. Diagnoses included heart failure, difficulty walking, muscle weakness, acute on chronic diastolic congestive heart failure, pleural effusions, dementia without behavioral disturbance, localized swelling, mass and lump in bilateral lower limbs, psychotic disorder with delusions due to known physiological condition, type 2 diabetes, malignant neoplasm of breast (cancer), chronic kidney disease, and encephalopathy (brain disease). Review of the care plan dated 02/23/22 revealed Resident #55 was at risk for behavior symptoms as she was experiencing auditory and visual hallucinations, removed clothing, refused medications and meals,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to ensure Resident #18, Resident #56, and Resident #58 had clothing protectors during all meals. This affected three (Resident #18, Resident #56, and Resident #58) of four residents observed requiring a clothing protector during meal service. Findings include: 1. Observation on 04/01/19 at 8:15 A.M. revealed residents were in the dining room eating breakfast. Resident #18, Resident #56, and Resident #58 were originally using a paper napkin as a clothing protector and then the napkin was replaced with a hand towel laying over their chest. Interview on 04/01/19 at 9:00 A.M. with State Tested Nursing Assistant (STNA) #817 verified they did not have clothing protectors during the observed breakfast meal. STNA #817 revealed laundry was supposed to restock the clothing protectors, and since there were none, they resorted to using towels. Interview on 04/01/19 at 9:08 A.M. with STNA #813 confirmed they were using towels instead of clothing protectors during the breakfast meal service. 2. Observation on 04/04/19 at 12:40 P.M. revealed…

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

Based on observations and interview, the facility failed to ensure Resident #30, Resident #53, Resident #60, and Resident #92 were supervised while eating during meal services. This affected all four (Resident #30, Resident #53, Resident #60, and Resident #92) of four residents observed eating without supervision in the dining room. Findings include: Observation on 04/01/19 at 8:44 A.M. revealed State Tested Nursing Assistant (STNA) #816 and STNA #813 left the dining room during breakfast meal service. Observation on 04/01/19 from 8:44 A.M. to 8:46 A.M. revealed the dining room was left unattended. STNA #817 entered the dining room at 8:46 A.M. Resident #30, Resident #53, Resident #60, and Resident #92 were still eating when no staff were in the dining room. Interview on 04/01/19 at 8:55 A.M. with STNA #813 revealed she did not realized STNA #816 was leaving the dining room when she left, and revealed the dining room should not be left unattended. Interview on 04/01/19 at 9:08 A.M. with STNA #813 revealed when she left the dining room she sent STNA #817 into the dining room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review, the facility failed to ensure residents were served the correct portion size of pureed dinner roll. This affected all five (Resident #86, Resident #59, Resident #37, Resident #66, and Resident #309) of five residents that were on a dysphagia or pureed textured diet. Findings include: Review of the diet spreadsheet for lunch on 04/03/19 revealed residents on a dysphagia and pureed diet should be served a number 12 scoop size pureed wheat roll. Review of the facility Diet Order Census list revealed Resident #86 and Resident #59 were ordered a dysphagia mechanically altered textured diet. Resident #37, Resident #66, and Resident #309 were ordered a pureed textured diet. Review of the Basis at a Glance information guide, revised 2002 revealed at number 16 scoop size is a fourth of a cup and a number 12 scoop size is a third of a cup. Observation on 04/03/19 at 12:05 P.M. revealed [NAME] #814 used a number 16 scoop size instead of a number 12 scoop size to serve pureed wheat roll. Interview on 04/03/19 at 12:05 P.M. with [NAME] #814…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review, the facility failed to maintain comfortable sound levels for Resident #65. This affected two (Residents #65 and #39) of six residents reviewed for comfortable environment. Findings include: Record review revealed Resident #65 was admitted on [DATE] and readmitted on [DATE] with diagnoses including but not limited to Charcot's left ankle foot joint, chronic kidney disease, heart failure, and atrial fibrillation. Resident #65's 01/05/19 quarterly minimum date set (MDS) revealed her cognition was intact. Interview with Resident #65 on 04/01/19 at 1:37 P.M. with Resident #65, in the resident's room, revealed the resident next door (Resident #39) yells all night and she is worried about not getting enough sleep with chemotherapy treatments starting. Observation at this time revealed Resident #39 was yelling which could be heard in Resident #65's room. Interview on 04/03/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #815 revealed Resident #39 does yell at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nail care was provided to a resident dependent for activities of daily living (ADLs). This affected one (Resident #12) of three residents reviewed for activities of daily living. The facility identified 47 residents as being dependent for ADLs. Findings include: Review of the record revealed Resident #12 was admitted on [DATE] with diagnoses including chronic respiratory failure and cerebral infarction. Review of the significant change Minimum Data Set (MDS) 3.0 dated 02/22/19 indicated the resident was severely cognitively impaired and was totally dependent for bed mobility, dressing, toileting, eating, and personal hygiene. The resident was on hospice care. Resident #12 had a care plan initiated 02/28/19 for ADL self care deficit. The plan included staff to provide total assistance with ADLs. During an observation on 04/01/19 at 10:20 A.M., Resident #12's fingernails on the right hand were noted to be long with a brown colored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to ensure medication was administered as ordered for one resident (Resident #79) out of five residents reviewed for unnecessary medications. Findings include: Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses including respiratory failure, neuromuscular dysfunction, hypertension, acute tracheitis, and type two diabetes. Resident #79's admission Minimum Data Set (MDS) 3.0 assessment revealed Resident #79 to have intact cognition scoring a fifteen on the Brief Interview for Mental Status (BIMS). Review of Resident #79's medical record revealed an order for Heparin Sodium (an anticoagulant medication) to inject 7500 units subcutaneously every eight hours. Review of Resident #79's Medication Administration Record (MAR) for the month of March, 2019 revealed Resident #79 did not receive the ordered Heparin doses for the four following times: 1. 2:00 P.M. dose on 03/04/19 2. 10:00 P.M. dose on 03/18/19 3. 6:00 A.M. dose 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 observation, interview, and record review, the facility failed to ensure labeling and storage of medication. This affected seven of 102 residents residing in the facility (Residents #1, #202, #203 #14, #70, #81, and #92). Findings include: 1. Review of the record revealed Resident #1 was admitted on [DATE]. He had a physician order dated 02/27/19 for insulin lispro solution inject as per sliding scale: if blood sugar 70-150=0 units, 141-200=1 unit, 201-250=2 units, 251--300=3 units, 301-350=4 units, 351-400=5 units, greater than 400 give 5 units then call MD, subcutaneously before meals and at bedtime for diabetes. During a medication administration observation on 04/02/19 at 4:38 P.M., Licensed Practical Nurse (LPN) #804 administered insulin to Resident #1. The resident's blood sugar was 235. The LPN prepared lispro insulin (Humalog) 2 units. Review of the 10 milliliter insulin vial revealed no indication which resident it belonged to. On 04/02/19 at 4:49 P.M., LPN #804 confirmed there was no name 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 observation, interview, record review, and review of facility policies, the facility failed to ensure staff provided care in a manner to prevent the spread of infection. This affected one (Resident #28) for maintenance of a urinary catheter and during catheter care of one resident reviewed for urinary catheters and one (Resident #64) during incontinence care of one resident reviewed for urinary tract infections. Findings include: 1. Review of the record revealed Resident #28 was admitted on [DATE] with diagnoses including paraplegia, pressure ulcer sacral region, pressure ulcer buttock, and neuromuscular dysfunction of bladder. The resident had a physician order dated 01/22/19 to maintain Foley (urinary) catheter for neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 02/08/19 indicated Resident #28 was cognitively intact, needed extensive assistance with activities of daily living, and had functional limitations in range of motion to both upper and lower extremities. She 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.