Aventura At Walton Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure weekly skin observations were accurately completed as ordered for Residents #33 and #72. This affected two residents (#33 and #72) out of three residents for wounds. The facility census was 71. Findings include: 1. Review of Resident #33's medical records revealed an admission date of 10/22/24. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, neurogenic bowel, history of COVID-19, colostomy, and cannabis dependence. Review of Resident #33's physician orders for March 2025 revealed an order to cleanse the right lateral ankle with normal saline (NS) or wound cleanser, pat dry, apply collagen to the wound and cover with boarder gauze every Monday, Wednesday, and Friday night shift and as needed (PRN). Review of Resident #33's Medication Administration Record (MAR) and Treatment Administrative Record (TAR) for October 10/23/24 revealed wound treatment was current for Stage 3 pressure ulcer (full thickness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and interview, the facility failed to ensure staff followed enhanced barrier precautions during catheter care. This affected one (Resident #15) of three residents reviewed for catheters. The facility census was 72. Findings include: Review of the medical record for Resident #15 revealed an admission date of 10/22/24 with diagnoses including paraplegia (paralysis of the legs and lower body) and neuromuscular dysfunction of the bladder (condition where nervous system injury or disease affects the bladder). Review of the physician's orders for Resident #15 revealed an order dated 12/03/24 for catheter care every shift. He also had an order dated 01/13/25 for enhanced barrier precautions. Observation of catheter care to Resident #15 on 02/11/25 at 9:18 A.M. with Licensed Practical Nurse (LPN) #206 revealed he was on enhanced barrier precautions. There was a sign for enhanced barrier precautions on his door stating that all staff must wear gloves and gown when providing hygiene and care of urinary catheter. There was noted to be an isolation cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure residents were treated in a respectful and dignified manner. This affected three residents (#31, #68, and #70) of six observed for dignified treatment. The facility census was 71. Findings include: 1. Review of Resident #31's medical records revealed an admission date of 06/03/24. Diagnoses included developmental disorder, bladder dysfunction and Parkinson. Review of MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. Resident #31 required maximum assistance with toileting, bathing and personal hygiene. Resident #31 had a urinary catheter for elimination. Review of Resident #31's physician orders for January 2025 revealed to keep foley bag covered with privacy bag. Observations on 01/13/25 from 11:16 A.M. to 11:20 A.M. revealed Resident #31's urinary drainage bag was visible from the doorway and did not have privacy cover in place. Resident #31 was not interviewable. Interview with Certified Nurse Aide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and family interview, and review of the facility policy, the facility failed to ensure residents and their responsible parties were included in the development and implementation of the plan of care. This affected one resident (Resident #11) of three residents reviewed for care planning. The facility census was 71. Finding include: Review of Resident #11's medical records revealed an admission date of 10/22/24. Diagnoses included paraplegia and bladder dysfunction. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Telephone interview on 01/13/25 at 10:33 A.M. with Resident #11's Power of Attorney (POA) revealed she had attempted multiple times to arrange a care planning conference to discuss Resident #11's needs, however no care planning conference had ever been scheduled. Interview on 01/13/25 at 3:03 P.M. with Social Services Designee (SSD) #332 revealed care planning conferences were to be done upon admission and then on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to timely address resident and family concerns. This affected two residents (#11 and #67) of four residents reviewed for concerns. The facility census was 71. Findings include: Review of the facility's grievance log revealed no logged grievances for December 2024 or January 2025 to date. 1. Review of Resident #11's medical records revealed an admission date of 10/22/24. Diagnoses included paraplegia and bladder dysfunction. Resident #11's record indicated he had a chronic, indwelling suprapubic (surgically created opening in the abdomen in which a urinary catheter is inserted into to allow for continuous bladder drainage) catheter present upon admission. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Resident #11 was dependent with toileting, and required maximum assistance with bathing and personal hygiene. Resident #11 had a urinary catheter for elimination. 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 record review, interview, review of facility policy, and review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), the facility failed to timely report an allegation of staff to resident verbal abuse to the State Agency as required. This affected one resident (Resident #72) of three residents reviewed for abuse. The facility census was 71. Findings include: Review of Resident #72's medical records revealed an admission date of 12/02/23. Diagnoses included Alzheimer's and failure to thrive. Review of MDS dated [DATE] revealed Resident #72 had impaired cognition. Resident #72 required maximum assistance with toileting, bathing, and personal hygiene tasks. Review of the ODH CALS website revealed an incident of alleged emotional/verbal abuse involving CNA #318's interactions with Resident #72 was reported to the State Agency on 01/13/25 at 12:08 P.M. Interview on 01/13/25 at 1:02 P.M. with Receptionist #278 revealed on 01/11/25 she had observed CNA #318 yelling at Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate urinary catheter care had been performed. This affected one Resident (#11) of three observed for catheter care. The facility identified five residents with indwelling urinary catheters. The facility census was 71. Findings include: Review of Resident #11's medical records revealed an admission date of 10/22/24. Diagnoses included paraplegia and bladder dysfunction. Resident #11's record indicated he had a chronic, indwelling suprapubic (surgically created opening in the abdomen in which a urinary catheter is inserted into to allow for continuous bladder drainage) catheter present upon admission. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. Resident #11 was dependent on staff for toileting, and required maximum assistance with bathing and personal hygiene tasks. Resident #11 had a urinary catheter for elimination. Review of 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 record review, Self-Reported Incident (SRI) review, police report review, policy review, and interview, the facility failed to prevent the exploitation of Resident #33 by an employee. This affected one (Resident #33) of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #33 revealed an admission date of 07/31/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant left side, dysphagia (difficulty swallowing), personality disorder, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/24, revealed Resident #33 had intact cognition and was independent for bed mobility, transfers, and eating. Review of the plan of care dated 11/22/24 revealed Resident #33 had problematic behavior characterized by inappropriate sexual behavior including making inappropriate remarks and attempting to touch other residents and staff. Review of SRI #254363 with a creation date of 11/22/24 revealed on 11/21/24 at around 12:00 P.M. there was an incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #50's pressure ulcer wound care was completed as ordered. This finding affected one (Resident #50) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, generalized anxiety disorder and unspecified osteoarthritis. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #50's admission Nursing Evaluation form dated 08/05//24 revealed the resident had bruising to the right antecubital, right buttock and left buttock. Review of Resident #50's Wound Observation form dated 08/06/24 revealed the resident had bilateral buttocks dermatitis first acquired 08/05/24. The resident was discharged from wound care. Review of Resident #50's Braden Scale for Predicting Pressure Sore Risk form dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident safety when not returning from a leave of absence. This affected one Resident (#27) of three reviewed for safety hazards. The facility census was 72. Findings include: Review of the medical record for Resident #27 revealed an admission date of 03/01/24. Diagnoses included epilepsy, diabetes mellitus, Wernicke's encephalopathy, generalized muscle weakness, major depressive disorder, cognitive communication deficit, alcohol use, restlessness and agitation, and anxiety disorder. Review of the Medicare Quarterly Minimum Data Set (MDS) assessment, dated 06/07/24, revealed Resident #27 had intact cognition. Resident #27 was independent for bed mobility, ambulation, and transfers. Review of physician's order, dated 08/09/24, revealed Resident #27 may go on leave of absence (LOA) with supervision with medications unless contraindicated. Review of physician's orders for September 2024 revealed Resident #27 had orders for Empagliflozin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a Self-Reported Incident (SRI), facility investigation interviews, police report and facility policy review, the facility failed to ensure Resident #22 was free from suspected resident-to-resident sexual abuse by Resident #63. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 69. Finding include: Review of the medical record for Resident #22 revealed an admission date of 05/24/21. Diagnoses included adult failure to thrive, dementia, hearing loss, psychosis, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was rarely or never understood. She was totally dependent on two people for toileting and hygiene and required extensive assistance of two people for bed mobility, transfers, and dressing. She displayed behavioral symptoms not directed toward others such as disrobing in public, scratching, or hitting herself and disruptive sounds daily. Review of the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete wound care as ordered/care planned. This affected one resident (#58) of two observed for wound care. The facility identified seven residents (#2, #17, #27, #35, #45, #58, and #68) who required wound care. The facility census was 70. Findings include: Review of Resident #58's medical records revealed an admission date of 05/01/23. Diagnoses included stage four pressure ulcer of the sacrum (tailbone) and osteomyelitis (bone infection). Review of the care plan dated 06/20/23 (revised 08/22/23) revealed Resident #58 had impaired skin integrity with a stage four pressure ulcer to the sacrum. Interventions included perform wound care as ordered. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was rarely understood and was admitted with a stage four pressure ulcer to the sacral area. Review of Resident #58's current physician orders for August 2023 revealed orders to cleanse the left lateral leg with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure adequate urinary catheter care was provided. This affected one resident (#58) of one observed for urinary catheter care. The facility identified six residents (#17, #32, #44, #58, #67 and #68) with urinary catheters. The facility census was 70. Findings include: Review of Resident #58's medical records revealed an admission date of 05/01/23. Diagnoses included neuromuscular bladder, dementia and a sacral (tailbone) pressure ulcer. Review of the care plan dated 06/20/23 (revised 08/22/23) revealed Resident #58 had an indwelling urinary catheter. Interventions included to provide catheter care as ordered. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was rarely understood, had a urinary catheter and was incontinent of bowel. Review of current physician orders for August 2023 revealed provide catheter care every shift and check placement of catheter tubing anchor every shift. Observation on 08/28/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure adequate Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids and medications) care. This affected two residents (#55 and #58) of three observed for PEG tube care. The facility identified five residents (#24, #37, #35, #55 and #58) with PEG tubes. The facility census was 70. Findings include: 1. Review of Resident #58's medical records revealed an admission date of 05/01/23. Diagnoses included dysphasia (difficulty swallowing) and dementia. Review of the care plan dated 06/20/23 (revised 08/22/23) revealed Resident #58 was at risk for malnutrition related to dysphasia. Resident #58 relied on nutrition received via PEG tube. Interventions included provide tube feeding per orders and monitor skin integrity for changes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was rarely understood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview the facility failed to ensure resident and/or responsible parties received quarterly statements of resident personal needs account activity as required. This affected four (Residents #24, #25, #33, and #49) of four residents reviewed for personal funds. This had the potential to affect 22 additional residents (Residents #1, #3, #6, #7, #8, #10, #13, #14, #18, #23, #26, #29, #32, #36, #37, #38, #47, #50, #53, #55, #56, and #58) who also had personal needs bank accounts at the facility. The facility census was 60. Findings include: Review of the resident funds list provided by the facility during the annual survey beginning on 11/20/22 revealed 26 (Residents #1, #3, #6, #7, #8, #10, #13, #14, #18, #23, #24, #25 #26, #29, #32, #33, #36, #37, #38, #47, #49, #50, #53, #55, #56, and #58) had an account that was actively managed by the facility. Review of four (Residents #24, #25, #33, and #49) of the 26 personal funds accounts revealed no documented evidence was provided by the facility indicating the residents and/or responsible parties were…

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

Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect 58 out of 60 residents receiving food from the facility. Two residents (Residents #2 and #4) out of 60 residents received nothing by mouth. The facility census was 60. Findings include: During the initial kitchen tour conducted on 11/20/22 between 8:37 A.M. through 8:47 A.M. revealed Dietary Aide (DA) #500 was not wearing a hairnet. DA #500 stated that there were no hairnets available. In the walk-in refrigerator revealed ambrosia salad was portioned into souffle cups and not covered, labeled, or dated. Mashed potatoes and gravy were not labeled or dated. [NAME] # 212 verified the findings at 8:47 A.M. on 11/20/22. [NAME] #212 stated that the Dietary Manager is in the hospital and the department is short staffed today. A follow up visit to the kitchen on 11/21/22 at 9:32 A.M. revealed that DA #205 was still not wearing a hair restraint. DA #205 stated that she just took it off to wash dishes then went to her bookbag,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually. This had the potential to affect all residents. The facility census was 60. Findings Include: Review of the facility assessment revealed the facility assessment was completed on 10/09/17 and reviewed on 11/21/17, 11/24/18, 02/06/19, 06/24/19, 07/30/19, 11/25/19, 03/23/20, 05/18/20, and 06/14/21. Review of the facility assessment revealed it had not been reviewed or updated since 06/14/21. Interview with the Administrator on 11/22/22 at 3:40 P.M. verified the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Resident #6 and Resident #11. This affected two of two residents reviewed for call light placement. The facility census was 60. Findings Include: 1. Review of the medical record for the Resident #6 revealed an admission date of 07/07/18. Diagnoses included epilepsy, diabetes, and a history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/22, revealed the resident had intact cognition. Resident #6 was independent for bed mobility, transfers, walking, locomotion, dressing, eating, and toilet use. Resident required supervision for personal hygiene. Observation of the resident on 11/20/22 at 9:46 A.M. revealed his call light not within reach. It was hung over the call light box over the roommate's bed which was several feet away from the Resident. Review of care plans dated 07/09/18 with a revision date of 02/20/20 revealed Resident #6 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to honor resident preferences regarding getting out of bed to participate in activities and or socialize, and going back to bed. This affected one resident, Resident #1, of one resident reviewed for choices. The facility census was 60. Findings include: Record review for resident #1 revealed an admission date of 02/14/17. Diagnosis included cerebral palsy and muscle weakness. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident #1 required extensive assistance of two plus persons for bed mobility, activity did not occur for transfers or locomotion, and Resident #1 had no concerns with mood or behaviors. Record review of the care plan dated 05/01/22 revealed Resident #1 preferred activities included playing bingo and interacting with staff. Interventions included to provide Resident #1 with a program of activities that 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 record review and staff interview the facility failed to ensure Pre admission Screen and Resident Review (PASRR) forms were completed timely as required and addressed all applicable mental health and developmental disability diagnoses. This affected one of one resident reviewed for PASRR compliance. The facility census was 60. Findings Include: Resident #54 was admitted to the facility on [DATE] diagnoses that included schizoaffective disorder, intrahepatic bile duct carcinoma , hypertension and severe protein-calorie malnutrition. Further review of the medical record revealed Resident #54 was admitted to the facility on a hospital exemption form which in turn required the completion of the PASRR form within thirty days of admission. Review of the PASRR in the medical record revealed Resident #54 PASRR was completed on 11/07/22. Interview with Registered Nurse (RN) #209 confirmed a PASRR should have been completed on 11/04/22 and was not completed timely as required.

Based on observation, record review and interview the facility failed to ensure timely nail care was provided for Resident #6, Resident #26, and Resident #42. This affected three of three residents reviewed for providing assistance with nail care. The facility census was 60. Findings Include: Review of the medical record for the Resident #6 revealed an admission date of 07/07/18. Diagnoses included epilepsy, diabetes, and a history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/22, revealed the resident had intact cognition. The Resident required supervision for personal hygiene. Observation on 11/20/22 at 9:22 A.M. and 09:46 A.M. revealed Resident #6's nails were long, jagged, and split. Interview on 11/20/22 at 9:46 A.M. Resident #6 said he usually cut his own nails but had lost his clippers. Interview on 11/20/22 at 12:20 P.M. Assistant Director of Nursing (ADON) #262 verified Resident #6's nails needed to be cut. ADON #262 stated she would check with the Resident's physician to see if he would be allowed to have his own…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide ongoing activities to meet the interest and needs for one resident, Resident #1, of one resident reviewed for activities. The facility census was 60. Findings include: Record review for resident #1 revealed an admission date of 02/14/17. Diagnosis included cerebral palsy and muscle weakness. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident #1 required extensive assistance of two plus persons for bed mobility, activity did not occur for transfers or locomotion, and Resident #1 had no concerns with mood or behaviors. Record review of the care plan dated 05/01/22 revealed 1:1 visits from activities staff to promote socialization. Resident #1 preferred activities included playing bingo and interacting with staff. Interventions included to provide Resident #1 with a program of activities that was of interest and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure an effective bowel regimen was implemented for Resident #52 after the resident did not have a bowel movement for nine days and failed to ensure Resident #52's left elbow cushion was available and applied at all times per the physician orders. This affected one resident (Resident #52) of one resident reviewed for bowel monitoring and interventions for pressure wounds. The facility census was 60. Findings include: 1. Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder, epilepsy, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was severely cognitively impaired, required extensive assistance with two staff for activities of daily living except eating was total with one staff and was incontinent of bowel and bladder. Resident #52 had an unhealed pressure ulcer, one stage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to ensure the physicians order for splints was followed for residents #3 and #9. This affected two of two residents reviewed for splint placement. The facility census was 60. Findings Include: 1. Diagnoses included aphasia, hemiplegia and hemiparesis, and contracture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/08/22, revealed the resident had impaired cognition. The resident was totally dependent for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was independent for eating. Review of physician orders for 11/22 revealed an order dated 09/22/22 for Resident #3 to wear a right resting hand splint daily as tolerated. Review of the plan of care dated 08/30/16 and last revised 04/25/22 revealed Resident #3 was to use a hand/wrist/elbow splint for right upper extremity contracture prevention. Interventions included to wear right elbow extension splint daily as tolerated. Review of the Medication Administration Record (MAR) or Treatment Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide physician ordered/dietary recommended nutritional supplements for one resident, Resident #29, of three residents reviewed for nutrition. The facility census was 60. Findings include: Record review revealed Resident #29 had an admitting date of 08/27/20. Diagnosis included hyperthyroidism, diverticulitis, and gastro esophogeal reflux disorder (GERD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had moderate cognitive impairment and required supervision with eating. Resident #29 had weight loss not prescribed. Record review of Resident #29's weight record revealed on 06/03/22 Resident #29's recorded weight was 110 pounds. On 11/15/22 Resident #29's recorded weight was 97.8 pounds (down 11.9 %). Review of the care plan dated 07/11/22 revealed Resident #29 significant weight loss over 30 days noted 9/15/22. Interventions included to provide diet per order and provide supplements per order. 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 staff interview, observation, medical record review, and facility policy review, the facility failed to ensure Resident #266 Continuous Positive Airway Pressure (CPAP) machine was maintained in functional order. The facility identified one resident (#266) who utilized a CPAP machine. The facility census was 60. Findings include: Resident #266 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, sleep apnea, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, bipolar disorder, and anxiety disorder. Review of the admission Nursing Evaluation assessment dated [DATE] revealed Resident #266 was alert and oriented to person, place, and time and required two-person physical assist to total dependence for activities of daily living (ADLs). Review of the 48-Hour baseline care plan dated 11/14/22 revealed Resident #266 had ineffective breathing related to asthma and obstructive sleep apnea. Review of the care plan revealed interventions that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, the facility failed to ensure residents request and preferences for meals were honored. This affected two (Resident #40 and #41) of 58 residents who received meals from the kitchen. Residents #2 and #4 received no food by mouth. The facility census was 60. Findings Include: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses including hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, chronic kidney disease obesity, and other intestinal obstruction unspecified as to partial versus complete obstruction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was alert and oriented to person, place, and time and required two-person physical assist for activities of daily living (ADLs). Review of the physician orders revealed Resident #40 had an order dated 07/31/22, for a cardiac prudent diet, regular texture, and thin consistency. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain infection control practices during wound care provided for one Resident, Resident #52, of one resident reviewed for pressure ulcers. The facility census was 60. Findings include: Record review for Resident #52 revealed an admission date of 12/17/21. Diagnosis included pressure ulcer of sacral region stage four, personal history of transient ischemic attack (TIA), and muscle weakness. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 (Resident #52 was unable to complete the assessment). Resident #52 had an unhealed pressure ulcer, one stage three pressure ulcer not present on admission. Record review of the physician orders for Resident #52 for November 2022 revealed orders for the left elbow: Cleanse area with normal saline, pat dry, pack with calcium alginate and cover with an abdominal pad and wrap with kerlix. Change daily and as needed. Observation…

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

Based on observation, record review and interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent contamination and/or food borne illness. This affected all 63 of 63 residents who received meal trays from the kitchen. The facility identified one resident (#24) who received nothing by mouth. The facility census was 64. Findings include: Initial kitchen tour on 12/15/19 at 8:08 A.M. with [NAME] #13 revealed gray/black debris, crumbs, and scuff marks covering floor in main kitchen, and additional storage rooms adjacent to the kitchen. Additional observations revealed a clear sticky substance, and a cup on the floor behind the juice machine. A follow up observation of the kitchen on 12/16/19 at 10:30 A.M. revealed a can opener laying on a metal cart with a crusty, orange, dried substance on the blade. The bottom shelf of the cart had food particles, a dried crusty brown material, and dried white drop marks on it. The side of the pallet warmer next to the metal cart had dried, whitish drip marks covering the entire surface. 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, record review and interview the facility failed to ensure pureed foods were served at a palatable and smooth consistency for safe swallowing. This affected eleven residents (#3, #7, #24, #26, #28, #30, #37, #39, #41, #53 and #216) who were prescribed a pureed diet of 63 residents who consumed meals from the facility's kitchen. Findings include: On 12/16/19 at 10:28 A.M. observation of the preparation of pureed foods with [NAME] # 74 revealed the rice was taking a long time to pureed. [NAME] #74 revealed he thought he had to cook it more to puree it better. The surveyor requested to taste the rice once it was ready to be served. On 12/16/19 at 12:12 P.M. a test tray of the lunch meal revealed the pureed rice was gritty and the pureed meat had small pieces of gristle in it. The mixtures were not smooth and not of the proper consistency. [NAME] #85 verified the consistency of the pureed rice and pureed meat. Review of resident diet list revealed eleven residents, Resident #3, #7, #24, #26, #28, #30, #37, #39, #41, #53 and #216 who were prescribed a pureed diet.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #62 and Resident #214 had accurate advance directive orders and information in place throughout their medical records. This affected two residents (#62 and #214) of two residents reviewed for advanced directives. Findings include: 1. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease and dementia with behavioral disturbance. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was rarely understood and required extensive assistance for activities of daily living. Review of the physician's orders for Resident #62 revealed an order dated 11/23/19 for a Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only comfort measures would be initiated in the event of a medical emergency). Review of the social service progress noted dated 11/23/19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure a seat belt device was properly assessed as a restraint for Resident #25 and failed to ensure the device was the least restrictive device for the resident. This affected one resident (#25) of two residents reviewed for seat belt devices. Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including schizophrenia, unspecified dementia with behavioral disorder, hemiplegia (paralysis) and hemiparesis (slight paralysis) following non traumatic subarachnoid hemorrhage affecting the left side. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/05/19 revealed Resident #25 was cognitively impaired and required total dependence with two plus person physical assist for transfers and toileting, and total dependence with one person physical assist for locomotion on and off the unit. Review of the physician's orders revealed an order, dated 12/10/19 for the use of seat belt when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure the physician's diet order for Resident #59 was followed. This affected one resident (#59) of four residents reviewed for nutrition. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including morbid obesity, metabolic syndrome, diabetes mellitus, major depressive order and chronic obstructive pulmonary disease. Resident # 59's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and was independent for mobility and eating. Review of a nutritional assessment, dated 11/25/19 revealed the resident just had bariatric surgery. The bariatric dietitian and facility registered dietitian agreed Resident #59 should start a low concentrated sweet (LCS) regular (soft foods), thin liquids diet and with small portions. Review of the physician's orders, dated 12/13/19 revealed an order for a small portions…

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