Urbana Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, Resident Council meeting, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state agency. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent assistance for eating, toileting, bed mobility, and transfers. He was always continent for bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed the CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and resident interview, resident council meeting, and facility policy review, the facility failed to ensure an investigation was initiated for a allegation of abuse. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent for eating, toileting, bed mobility, and transfers. He was always continent of bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed the CNA #240 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 and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for residents who had hospice services. This affected two residents, (Residents #3 and #14) of two residents reviewed for hospice services. The facility census was 46. Findings Include: 1. Record review of Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 include dementia, anxiety, stage four kidney disease, heart disease, and shortness of breath. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for transfers and mobility. The resident received hospice services starting on 11/23/24. Review of Preadmission Screening and Resident Review (PASRR) records for Resident #3 revealed no PASRR was completed when hospice services were initiated for the resident. 2. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, review of the care conferences and facility policy review, the facility failed to ensure residents received routine care conferences. This affected two (#29 and #39) of three residents reviewed for care conferences. The census was 46. Findings included: 1. Medical record review for Resident #29 revealed an admission date of 11/04/18. Medical diagnoses included coronary artery disease, heart failure, hypertension, and diabetes. Review of the care conferences for Resident #29 revealed there were documented care conferences on 10/10/24 and on 02/27/25. Review of the quarterly MDS dated [DATE] revealed Resident #29 was cognitively intact. Interview with the Resident #29 on 06/03/25 at 11:25 A.M. revealed she had not had a care conference every three months. Interview with Social Services Designee (SWD) #214 on 06/05/25 at 10:01 A.M. revealed she was supposed to complete care conferences every three months and she was running behind. 2. Medical 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 observation, medical record review, and staff interview, the facility failed to ensure a safe homelike environment was free on unsecured potential poisonous chemicals. This affected one (#37) of 46 residents observed in the facility for potential hazards. The facility census was 46. Findings included: Observations on 06/02/25 through 06/04/25 from 9:45 A.M. to 3:30 P.M., revealed the following environmental issues. The shower room closet located in the short A unit hallway had a closure which was easily unlocked and had a bottle labeled disincentive chemical cleaner. The warning label stated to keep out of the reach of children. In the unlocked B hall unit shower room, there was a gallon size container, with a nozzle sprayer and tubing attached, on the floor. It contained a clear liquid. There was no label on the container to identify the liquid. Observations from 06/09/25 from 9:45 A.M through 3:30 P.M. revealed Resident #37 wandering in hallways, rooms and common areas, including the A and B units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, the facility failed to ensure a restricted liquid diet was honored. This affected one (#39) of two reviewed for hydration during the annual survey. The census was 46. Findings include: Medical record review for Resident #39 revealed an admission date of 10/26/23. Medical diagnoses included heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was independent for eating, toileting, bed mobility, and setup or clean-up assistance for transfers. She was always continent for bowel and bladder. Review of the physician's order dated 04/30/25 revealed Resident #39 was on a fluid restriction to give 1200 cubic centimeters (cc) for a 24-hour period. Dietary to give 840 cc's total, for breakfast 360 cc's, for lunch 240 cc's, and dinner 240 cc's. Observation of Resident #39's lunch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, interview, pharmacy interview, policy, the facility failed to provide safe delivery of medication by crushing potassium 20 Milliequivalent for one resident (#15) out of residents reviewed on annual. The facility census was 46. Findings Included: Review of record revealed that Resident #15 had admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of Quarter MDS dated [DATE] revealed that BIMS was 1 that indicated she was severely cognitively impaired. Review of plan of care dated 08/21/24 revealed that Resident #15 had a risk for cardiac that had arteriosclerotic heart disease. Intervention was to provide small meals or frequent rather than three large meals, encourage activity level, and administer medications as ordered. Review of physician order dated 08/21/24 revealed that Resident #15 had an order to crush medications unless contraindicated. Review of physician order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and facility policy review, the facility failed to ensure medications were not expired and the facility failed to provide safe storage and delivery of medication for one resident (#28). The facility census was 46. Findings Included: Observation on [DATE] at 8:40 A.M. of the overstock medication room, revealed there were seven bottles of Folic Acid 400 micrograms (mcg) with an expiration date was 02/2025. Interview on [DATE] at 8:40 A.M. with Registered Nurse (RN) #204 it was verified the seven bottles of Folic Acid 400 mcg expired 02/2025. Each bottle was unopened and contained 250 tablets. Review of the facility document titled In House Stock dated unknown revealed that the facility did have Folic Acid 400 micrograms (mcg) over the counter for stock. Review of the facility policy titled Storage and Expiration Dating of Medications and Biological's dated [DATE] revealed the facility should ensure medications and biological's are stored in an orderly manner 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 medical record review, staff and resident interview and facility policy review, the facility failed to ensure a follow-up appointment was made for a resident who had a tooth that was broke off at the gum line. This affected one (#29) of four residents reviewed for dental services during the annual survey. The census was 46. Findings included: Medical record review for Resident #29 revealed an admission date of 11/04/18. Medical diagnoses included a stroke, coronary artery disease, heart failure, hypertension, and diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact. She was independent for eating, toileting, bed mobility and she required a Hoyer lift for transfers. She was always incontinent for bowel and bladder. Review of the resident's dental appointment dated 09/09/24 revealed the dentist tried to extract her tooth and the root was under the gum line and it wouldn't come out. He spoke to Social Services Designee (SSD) and Director 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 observation and resident interview, family member interview, and staff interview, the facility failed to ensure a resident was provided a pest free environment. This affected one (#11) of 46 resident rooms observed for pest. The facility census was 46. Findings include: Record review of Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident #11 include cerebral infarction, muscle weakness, dysphagia, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for dressing and transfers. Observation on 06/02/25 at 10:05 A.M., revealed the Resident #11 in room B 23. On 06/03/25, Resident #11 was moved into room B 21. Observation on 06/03/25 at 8:30 A.M. revealed 10 to 20 quarter length black insects with wings on the floor in Resident #11 previous room, room B23. There were no insects observed in the B 23 room on 06/02/25. Interview on 06/03/25 at 8:30 A.M., Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews with staff and the resident's emergency contact, and policy review, the facility failed to implement an effectivprovide a resident and/or emergency contact training on a mechanical lift and meal arrangements for a safe discharge. This affected one (#1) of three residents reviewed for discharge. The facility census was 45. Findings include: Closed record review for Resident #1 revealed he was admitted on [DATE] with diagnoses including a fractured heel, history of pulmonary embolism, diabetes mellitus with neuropathy, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition, was dependent on two staff for Hoyer lift transfers and did not ambulate. Resident #1 was his own person with an apartment in the community. His former wife was listed as his only emergency contact. Review of the physician orders dated 08/29/23 revealed an order for Resident #1 to discharge from the facility with home health nursing services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the facility's policy, and record review, the facility failed to ensure an interdisciplinary care conference was held and the resident's were invited to attend. This affected one (Resident #42) of one resident reviewed for care conferences. The facility census was 46. Findings include: Review of the medical record for Resident #42 revealed an admission date of 07/18/18. Diagnoses included joint pain, epilepsy, cognitive impairment, and non-compliance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact and was independent with mobility and required only minimal assistance from staff with personal hygiene. Review of the forms titled Interdisciplinary Care Conference Summary, dated 10/19/21, 01/18/22, and 04/19/22, revealed only the social services designee was in attendance. No clinical or other staff attended the meeting. The Interdisciplinary Care Conference Summary form, dated 07/21/22, revealed only the social services…

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

Based on staff interview, review of the facility's policy, and record review, the facility failed to timely provide a spend-down notification to a resident or representative and assist the resident in spending their balance before returning it to the State of Ohio. This affected one (Resident #22) of one resident reviewed for spend-down notifications. The facility census was 46. Finding include Review of the medical record for Resident #22 revealed an admission date of 03/07/14. Diagnoses included non-psychotic mental disorder and cognitive communication difficulty. Review of the spend-down notification dated 01/04/22 revealed Resident #22's balance was within $200 of the Medicaid limit or higher. This notification was to inform Resident #22 of the balance amount and provide information to reach out to the social worker within seven days to work out a plan to spend the balance. There was no evidence Resident #22 or representative were provided a spend-down notification in the year of 2021. Review of Resident #22's account statement dated 01/04/22 revealed a balance of $4,322.98. 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 staff interview, review of the facility's policy, observations, and record review, the facility failed to ensure a care plan was created related to resident's oxygen use and behaviors. This affected one (Resident #11) of one resident reviewed for care plans. The facility census was 46. Finding include: Review of the medical record for Resident #11 revealed an admission date of 06/21/22. Diagnoses included hypertension, edema, heart disease, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Review of Resident #11's care plan dated 07/17/22 revealed there was no mention of Resident #11 being on oxygen nor any mention of Resident #11's behaviors of pulling her oxygen out of her nose. Review of the physician orders dated 08/08/22 revealed an order for oxygen at two liters per nasal cannula for shortness of breath (SOB) and to keep oxygen saturations over 92 percent. The physician order dated 10/08/22 revealed an order for 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, review of the facility's policy, and staff interview, the facility failed to timely implement a wound treatment for a resident's new pressure ulcer. This affected one (Resident #15) of three residents reviewed for pressure wounds. The facility identified two current residents with pressure ulcers. The facility census was 46. Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/15/16. Diagnoses included functional quadriplegia, flaccid neuropathic bladder, obstructive and reflux uropathy, chronic pain, chronic obstructive pulmonary disease, sepsis, cutaneous abscess of back, open wound of lower back and pelvis, depression, pressure ulcer of right buttocks stage four (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed), and multiple sclerosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, observations, and record review, the facility failed to ensure staff placed a splint device on a resident according to the therapy recommendations and physician order. This affected one (Resident #30) of one resident reviewed for positioning and mobility. The facility identified two residents with a physician-ordered splint device. The facility census was 46. Finding include: Review of the medical record for Resident #30 revealed an admission date of 11/21/19. Diagnoses included stiffness of the joint, lack of coordination, and hemiplegia and hemiparesis affecting her right side. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had an upper extremity impairment to the one side. Resident #30 did not have refusal of care during the assessment reference days. Review of the care plan dated 04/14/22 revealed Resident #30 had a right hand splint for a contracture management with staff to don (apply) the splint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of the facility policy, record review, and resident and staff interview, the facility failed to ensure smokeless tobacco products were secured. This affected one (Resident #23) of one resident reviewed for smoking. The facility identified one resident who wandered and had cognitive impairment. The facility census was 46. Findings include: Review of the medical record for Resident #23 revealed an admission date of 12/18/18. Diagnoses included cognitive communication deficit, paraplegia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Resident #23 required extensive assist of two staff for bed mobility and transfers. Resident #23 required total dependence of one for bathing, dressing, and toileting. Review of the care plan dated 07/16/22 revealed Resident #23 was a supervised smoker. The goals included the resident would maintain a safe smoking environment as evidence by not smoking violations through the next…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to timely act on pharmacy recommendations for three (#2, #10, and #14) of five residents reviewed for unnecessary medications. The facility census was 46. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and gastrointestinal symptoms. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and delusions. Review of the pharmacy recommendation dated 06/14/22 revealed Resident #2 received a Omeprazole 20 milligrams (mg) (proton pump inhibitor) in addition to another gastro protective therapy Cimetidine 200 mg once a day. The pharmacist recommended to discontinue Cimetidine. The physician declined recommendation and wrote the Cimetidine was for sexual behavior, The physician note on the pharmacy recommendation was dated 06/22/22. Review of the pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, the facility failed to attempt a gradual dose reduction (GDR) or provide a rationale for not attempting a GDR for a resident receiving an antidepressant. This affected one (Resident #14) of five residents reviewed for unnecessary medications. The facility census was 46. Findings include: Review of the medical record for Resident #14 revealed an admission date of 04/01/20. Diagnoses included depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of the physician order dated 06/30/21 to 07/21/22 revealed an order for Sertraline (antidepressant) 25 mg to be administered once daily. A second physician order dated 06/30/21 to 07/21/22 revealed an order for 50 mg Sertraline to be administered once daily. Further review of Resident #14's medical record revealed there was no evidence the physician attempted a GDR for Sertraline or an explanation of why the GDR was not attempted 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, observation, staff interview, and review of facility's infection policies and infection control log, the facility failed to identify and implement interventions to correct a concern with urinary tract infections as well as complete infection surveillance for August 2019. This affected 11 Residents (#14, #18, #27, #35, #39, #40, #41, #46, #98, #99, and #147) of 11 reviewed for infections. In addition the facility failed to ensure proper hand hygiene during wound care. This affected one (Resident #24) of one resident reviewed for wound care. The facility also failed to ensure proper food handling, related to hand hygiene, before touching residents food. This directly affected one (Resident #13) of one resident observed during a lunch observation. This had the potential to affect all 50 residents. The facility census was 50. Findings include: 1. Review Resident #13's medical record revealed she was admitted to the facility on [DATE] with diagnoses of hypertension, repeated falls, age…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, review of Resident Council Meeting records, review of the activity calendar, and review of facility policies; the facility failed to act promptly, respond to, and provide a rationale to Resident Council concerns in the areas of activities and appointment reminders. This affected two Resident's (#15 and #37) of three residents reviewed for Resident Council concerns. The census was 50. Findings include: 1. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, schizophrenia, dementia, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and was independent with her activities of daily living (ADL). Review of Resident Council Meeting Minutes dated 03/12/19 revealed the council was concerned there were no activities because staff were pulled to work the floor. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical records and staff interviews the facility failed to complete pain interviews on the Minimum Data Set (MDS). This affected two Resident's (#24 and #40) of 14 residents reviewed for comprehensive MDS assessments. The census was 50. Findings include: 1. Review of Resident #24's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, type two diabetes, and a pressure ulcer of sacral region (stage four). Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Section J of the MDS revealed the pain interview should be conducted. Resident #24 received as needed and scheduled pain medication. The resident interview for pain was not assessed. 2. Review of Resident #40's medical record revealed she was admitted to the facility 01/19/16. Diagnoses included acute kidney failure, chronic kidney disease (stage three), and dependence on renal dialysis. Review of Resident #40's 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 review of resident medical records, staff interview and review of facility policy, the facility failed to screen a resident for serious mental illness and developmental disability. This affected one (Resident #24) of three residents reviewed for appropriate Preadmission Screening and Resident Review (PASRR) completion. The facility census was 50. Findings include: Review of Resident #24's medical record revealed he admitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, type two diabetes, and a pressure ulcer of sacral region (stage four). Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Review of Resident #24's Hospital Exemption Form (7000 Form) dated 07/31/19 revealed the resident could reside in the facility for at least 30 days, pending a PASRR. Further review of Resident #24's medical record lacked evidence a PASRR had been completed. Interview on 11/04/19 at 1:02 P.M. with Social Service Designee (SSD) #136…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident medical records, staff interviews and review of facility policy, the facility failed to notify the state mental health authority and the intellectual disability authority after a significant change and a psychiatric hospitalization for residents who had mental illness and/or intellectual disability. This affected two Resident's (#36 and #37) of three residents reviewed for appropriate Pre admission Screening and Resident Review (PASRR) completion. The facility identified one resident who had a developmental disability and 20 residents with a documented psychiatric diagnoses. The facility census was 50. Findings include: 1. Review of Resident #36's medical record revealed she admitted to the facility on [DATE]. Diagnoses included: epilepsy, insomnia, mild cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and major depressive disorder with psychotic symptoms. Review of Resident #36's Minimum Data Set (MDS) revealed she was moderately cognitively impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, observation, resident and staff interview, review of activity records and review of facility's activity policy, the facility failed to provide activities as scheduled to meet the activity preferences and needs of residents. This affected two Resident's (#21 and #36) of two residents reviewed for activities. The census was 50. Findings include: 1. Review of Resident #36's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included: epilepsy, insomnia, mild cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and major depressive disorder with psychotic symptoms. Review of Resident #36's MDS dated [DATE] revealed she had a moderate cognitive impairment and it was somewhat important to do things with groups of people and to do her favorite activities. Review of Resident #36's care plan, last revised 08/03/18, revealed she enjoyed board games, cards, and talking with others. The care plan indicated her personal preferences would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, interview with facility staff, and review of facility policy, the facility failed to ensure ongoing communication with the dialysis center and failed to assess residents post dialysis. This affected one (Resident #40) of one resident reviewed for appropriate dialysis care. The facility identified Resident #40 was the only resident receiving dialysis services. The facility census was 50. Findings include: Review of Resident #40's medical record revealed she admitted to the facility 01/19/16. Diagnoses included acute kidney failure, chronic kidney disease (stage three), and dependence on renal dialysis. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. She required extensive assistance from staff with all activities of daily living. Review of Resident #40's care plan last revised 10/29/19 revealed she received dialysis treatments three times a week and would receive treatments as scheduled with monitoring of disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview the facility failed to ensure non pharmacological interventions were implemented before giving an as needed narcotic (Percocet). This affected one (Resident #40) out of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: Review of Resident #40's medical record revealed she was admitted to the facility on [DATE] with diagnoses of heart failure, respiratory failure, kidney disease (stage 3), schizophrenia, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. Her functional status was listed as totally dependent for transfers and toileting. Review of the care plan dated 06/05/19 revealed the resident used psychotropic medications daily related to diagnosis of anxiety disorder and depression. Review of the Medication Administration Record (MAR) dated for 10/2019 and 11/2019 revealed Resident #40 was administered Percocet (for pain) nine times (10/02/19, 10/03/19,…

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