Community Skilled Healthcare

Based on employee personnel file review, review of the facility assessment, review of the facility policy and interview, the facility failed to ensure staff had specialized training for the memory care unit. This had the potential to affect all residents (Residents #4, #5, #8, #10, #13, #14, #16, #17, #23, #30, #40, #42, #46, #47, #48, #50, #59, #64, #65, #66, #68, #72, #83, and #84) residing in the memory care unit The facility census was 83.Findings include: A review of the personnel file for Certified Nurse Aide (CNA) #844 revealed a date of hire as 01/28/26. Further review revealed CNA #844 had no specialized training for the memory care unit.A review of the personnel file for CNA #845 revealed a date of hire as 02/25/26. Further review revealed CNA #845 had no specialized training for the memory care unit.A review of the personnel file for CNA #846 revealed a date of hire as 07/31/25. Further review revealed CNA #846 had no specialized training for the memory care unit.A review of the personnel file for CNA #860 revealed a date of hire as 02/25/26. Further review revealed 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 record review, interview and observation the facility failed to ensure call lights were within reach for Residents #13, #76, and #84. This affected three (Residents #13, #49, and #84) of three residents reviewed for call lights. The facility census was 83.Findings include:1. Review of Resident #84's medical record revealed an admission date of 01/10/26. Diagnoses included malignant breast cancer, hypothyroidism, hypertension, adult failure to thrive, unspecified dementia, schizophrenia, and age-related osteoporosis.Review of Resident #84's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Resident #84 required setup or clean up assistance with eating, partial to moderate assistance with toileting hygiene, oral hygiene, and showering.An observation on 04/06/26 at 10:40 A.M. of Resident #84's call light revealed it was clipped to the privacy curtain out of reach of the resident.An interview on 04/06/26 at 10:41 A.M. with Resident #84 revealed if she…

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 facility policy review the facility failed to provide written notice of room changes to the resident and family representative. This affected one resident (#79) out of one resident reviewed for room change. The facility census was 83.Findings includeRecord review for Resident #79 revealed an admission date of 07/31/25 with diagnoses including unspecified intellectual disabilities, other seizures, unspecified psychosis not due to a substance or known physiological condition. Effective 03/11/26 Resident #79's brother was listed as Power of Attorney (POA).Review of Resident #79's progress notes revealed on 03/11/26 a social services entry stated, notified resident of room change. Resident is ok with room change. There was no documentation of evidence that Resident #79 received prior written notice of room change and that Resident's POA was provided written prior notice of room change.Review of a nursing note dated 03/17/26 revealed Resident #79 had a room change done, all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure residents were free from physical restraints. This affected one resident (Resident #66) of one resident reviewed for physical restraints. The facility census was 83.Findings include:Review of Resident #66's medical record revealed an admission date of 11/20/25. Diagnoses included moderate protein-calorie malnutrition, dementia, hyperlipidemia, mood disorder, urinary retention, age related osteoporosis, Alzheimer's disease, and anxiety disorder.Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition but was able to make needs known. Resident #66 required partial to moderate assist with all Activities of Daily Living (ADLs) including eating, showers, personal hygiene, dressing, and bed mobility.Review of Resident #66's care plan dated 02/01/26 revealed the resident was at risk for fluctuations and/or decline with ALDs due to multiple health…

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 residents were notified of bed hold information prior to discharge to the hospital and failed to notify the Ombudsman of hospitalizations. This affected two residents (Residents #2 and #5) of two residents reviewed for hospitalizations. The facility census was 83. Findings include:1.Review of the medical record for Resident #2 revealed an admission date of 08/24/23 with diagnoses including bipolar disorder, gender identity disorder, and borderline personality disorder.Review of the census data within the medical record revealed Resident #2 was hospitalized from [DATE] and returned to the facility on [DATE]. There was no evidence in the record of a bed hold notice. 2.Review of medical record for resident #5 revealed an admission date of 10/14/25 with diagnoses including unspecified dementia.Review of the census data within the medical record for Resident #5 revealed Resident #5 was hospitalized from [DATE] through 04/10/26. There was no evidence…

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 a care plan was developed to include discharge planning for Resident #77. This affected one resident (#77) of 47 residents reviewed for care plans. The facility census was 83.Findings include: Review of the medical record for Resident #77 revealed an admission date of 01/22/26. Diagnoses included chronic respiratory failure chronic obstructive pulmonary disease, type two diabetes mellitus without complications, and obesity.Review of the modification of admission MDS assessment dated [DATE] revealed Resident #77 was cognitively intact, had adequate hearing, was able to make himself understood, and understood others. Review of progress notes in Resident #77's medical record revealed on 02/06/26 a nursing note indicated Resident #77 wanted to return to his assisted living and he wanted to stay at the facility until renovations were completed. An additional nurse progress note dated 02/20/26 revealed a mini care conference took place in 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, observation, interview and facility policy review, the facility failed to administer a proper dose of acetaminophen (analgesic) to Resident #60. This affected one (Resident #60) of six residents observed for medication administration. The facility also failed to address x-rays in a timely manner for Resident #10. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 83.Findings include:1.A review of medical records for Resident #60 revealed the date of admission of 01/22/26. Significant diagnosis included osteoarthritis of the knee, unspecified, and pain in unspecified knee. Significant orders included acetaminophen 500 milligrams, give two tablets by mouth two times a day for pain. An admission minimum data set assessment (MDS) dated [DATE] revealed a brief interview for mental status with a score of 13 indicating Resident #60 was cognitively intact. The assessment also revealed Resident #60 received scheduled pain medication. The pain was rated as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to secure smoking materials for Resident #52. This affected one Resident (#52), who was identified as the facility's only smoker, of one resident reviewed for smoking and had the potential to affect all residents in the facility. The facility's census was 83.Findings include:A review of Resident #52's medical record revealed an admission date of 09/13/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus type II with hyperglycemia, atherosclerotic heart disease, depression, hypertension (HTN), myocardial infarction (MI), and lesion of the ulnar nerve of the left upper limb.A review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Further review of the MDS also revealed Resident #52 required set-up/supervision with all activities of daily living and required supervision with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, facility policy review and interview, the facility failed to ensure Resident #9's nasal spray was stored in a safe manner. This affected one (Resident #9) of six residents observed during medication administration. In addition, the facility failed to date a multi-dose vial of Tubersol (a liquid that is used to test if someone has been exposed to tuberculosis) in a manner to preserve efficacy. This had the potential to affect all residents who may require tuberculin skin testing using multi-dose vials. The facility census was 83.Findings include:1. A review of medical records for Resident #9 revealed the date of admission as 02/25/26. Significant diagnoses included chronic diastolic congestive heart failure. Significant orders included Fluticasone (corticosteroid nasal spray) 50 micrograms suspension, use one spray in each nostril daily for allergies. There were no orders to leave medications at the bedside of Resident #9.An admission Minimum Data Set (MDS) 3.0 assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and interview, the facility failed to ensure dental services were obtained for Resident #4. This affected one resident (Resident #4) of two residents reviewed for dental services. The facility census was 83.Findings include:A review of the medical records for Resident #4 revealed a date of admission of 03/09/22. Significant diagnosis included Alzheimer's disease with late onset, severe, with agitation.A review of the medical record for Resident #4 revealed a signed consent to treat for dental services dated 01/15/26. The consent to treat was signed by the Power of Attorney (POA) for Resident #4 because she wanted the resident fitted for dentures.A care plan dated 03/11/26 revealed Resident #4 to be edentulous (without teeth) and preferred not to wear dentures. Interventions included dental checkups as ordered.A review of an e-mail sent on 03/17/26 to 360 Dental Services from Social Services (SS) #823 revealed 360 Dental Services was contacted to schedule dental…

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, record review and facility policy review the facility failed to ensure attractive and palatable pureed food was served to Resident #39. This affected one Resident (#39) of three residents reviewed for food. The facility identified nine residents (#10, #35, #39, #41, #64, #65, #66, #74, #79) as receiving pureed diets. The census was 83.Review of the medical record for Resident #39 revealed an admission date of 04/26/25 with medical diagnoses including diaphragmatic hernia without obstruction or gangrene, other idiopathic peripheral autonomic neuropathy, and moderate protein-calorie malnutrition. The prescribed diet was listed as pureed texture, regular consistency and no added salt. An interview on 04/08/26 at 10:55 A.M. with Resident #39 revealed most days his pureed food was runny and not appealing. Observation on 04/08/26 at 12:39 P.M. of Resident #39's lunch tray revealed there were two pureed food items on the plate that did not hold form. One of the items was a brown circle of runny, thin consistency food (identified as Philadelphia cheesesteak)…

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 influenza and pneumococcal vaccines were addressed and administered timely for Resident #66. This affected one Resident (#66) of seven residents investigated for timely vaccination administration. The facility census was 83.Findings include:A review of Resident #66's medical record revealed an admission date of 11/20/25 with diagnoses including moderate protein-calorie malnutrition, unspecified dementia, unspecified mood disorder, osteoporosis, late onset Alzheimer's disease and anxiety.A review of Resident #66's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #66 required partial to moderate assistance with activities of daily living (ADL) bed mobility and transfers.A review of the immunization records for Resident #66 revealed neither influenza nor pneumococcal vaccines…

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 a COVID 19 vaccine was addressed and administered timely for Resident #66. This affected one Resident (#66) of seven residents investigated for timely vaccination administration. The facility census was 83.Findings include:A review of Resident #66's medical record revealed an admission date of 11/20/25 with diagnoses including moderate protein-calorie malnutrition, unspecified dementia, unspecified mood disorder, osteoporosis, late onset Alzheimer's disease and anxiety.A review of Resident #66's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 10 out off 15 which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #66 required partial to moderate assistance with activities of daily living (ADL), bed mobility and transfers.A review of the immunization records for Resident #66 revealed a COVID 19 vaccine had not been addressed or administered even…

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 the facility self-reported incident (SRI) and investigation and facility policy review, the facility failed to ensure resident-to-resident abuse did not occur between Resident #52 and Resident #40. This affected two (Residents #40, and #52) of six residents reviewed for abuse. The facility census was 91. Review of the medical record for Resident #40 revealed an admission date of 04/07/16. Diagnoses included autistic disorder, developmental disorder, anxiety, hypertension and scoliosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired. She required substantial assistance for eating and was dependent for oral care, toileting, showering, dressing and personal hygiene. Review of the medical record for Resident #52 revealed an admission date of 03/20/25. Diagnoses included diabetes, depression, high cholesterol, depression and respiratory disorders. Review of the quarterly MDS assessment 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 interviews, record reviews, review of facility Self-Reported Incidents (SRI), and review of facility policies the facility failed to ensure residents were free from misappropriation. This affected three residents (Residents #2, #26, and #94) of three residents reviewed for misappropriation. The facility census was 91.Findings include:1. Review of Resident #2's medical record revealed an admission date of 08/12/25. Diagnoses included Alzheimer's disease, moderate protein-calorie malnutrition, generalized anxiety disorder, folate deficiency, cognitive communication deficit, hypokalemia, and insomnia.Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired and required supervision with eating for partial/moderate assistance by staff for all other Activities of Daily Living (ADLs) including medication administration.Review of physician orders for Resident #2 dated August 2025 revealed there were no orders for Haldol (an antipsychotic…

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, review of facility Self-Reported Incidents (SRI), and review of facility policy, the facility failed to implement policies related to misappropriation. This affected one Resident (Resident #26) out of three residents reviewed for misappropriation. The facility census was 91.Findings include:Review of Resident #26's medical record revealed an admission date of 12/24/25. Diagnoses included attention deficit hyperactivity disorder (ADHA), drug induced secondary parkinsonism, lower back pain, bipolar disorder, cervicothoracic fusion of spine, gender identity disorder, borderline personality disorder, seizures, and Tourette's Disorder.Review of Resident #26's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was independent with all Activities of Daily Living (ADLs).Review of Resident #26's Physician orders dated March 2025 revealed the resident was ordered Amphetamine-Dextroamphetamine (Adderall) 20 milligrams (mg) twice daily at 8:00 A.M. and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the facility self-reported incident (SRI) and investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of resident-to-resident abuse. This affected two (Residents number #40 and #52) of six residents reviewed for abuse. The facility census was 91. Review of the medical record for Resident #40 revealed an admission date of 04/07/16. Diagnoses included autistic disorder, developmental disorder, anxiety, hypertension and scoliosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired. She required substantial assistance for eating and was dependent for oral care, toileting, showering, dressing and personal hygiene. Review of the medical record for Resident #52 revealed an admission date of 03/20/25. Diagnoses included diabetes, depression, high cholesterol, depression and respiratory disorders. Review of the quarterly MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and review of facility policy the facility failed to ensure Resident #93 received a safe and complete discharge process. This affected one resident (Resident #93) out of four residents reviewed for discharge. The facility census was 91.Review of Resident #93's medical record revealed an admission date of 10/03/25 and a discharge date to home on [DATE]. Diagnosis included Rhabdomyolysis, moderate protein-calorie malnutrition, hypertensive chronic kidney disease stage V, seizures, hypothyroidism, anemia, hyperfunction of pituitary gland, urinary retention, hyperlipidemia, diabetes insipidus, and hypopituitarism.Review of Resident #93's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and required set up or clean up assistance for Activities of Daily Living (ADLs).Review of Resident #93's progress notes dated 11/03/25 authored by Licensed Practical Nurse (LPN #222) revealed she was the nurse who discharged Resident #93…

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 and review of the facility policy, the facility failed to ensure sufficient staffing to meet the needs of all residents. This affected three (Residents #35, #67 and #69) of six residents reviewed for showers and had the potential to affect all 75 residents in the facility. Findings include: Interview on 06/10/25 at 8:31 A.M. with certified nurse aide (CNA) #200 revealed she had several residents who required a Hoyer lift (mechanical lift) for transfer, assistance with feeding and activities of daily living (ADL) care. She revealed showers often did not get done because there was not enough staff to complete them. Interview with Resident #69 and family on 06/10/25 at 10:33 A.M. revealed the resident did not receive bathing per their preferred method or frequency. Resident #69's family indicated they have voiced concerns to floor staff and facility administration. Interview on 06/10/25 at 10:46 A.M. with CNAs #203 and #204 reviewed facility staffing was horrible. CNA #204…

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

Based on review of the facility schedule and interview, the facility failed to ensure a Registered Nurse (RN) was in the facility for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 75 residents in the facility. Findings include: Review of the schedules for May 2025 as well as the staffing tool for the weeks of 05/11/25 and 05/18/25 revealed the facility did not have an RN scheduled to work on 05/13/25. One RN worked 7.25 hours on 05/23/25. Interview on 06/11/25 at 2:13 P.M. with the Director of Nursing (DON) verified she had no other evidence to verify an RN had worked eight consecutive hours on 05/13/25 or 05/23/25. This deficiency was an incidental finding identified during the complaint investigation.

Based on review of the Facility Assessment and interview, the facility failed to ensure the facility assessment was updated annually. This had the potential to affect all 75 residents in the facility. Findings include: Review of the Facility Assessment revealed a date of 04/18/22. Interview on 06/11/25 at 11:59 A.M. with the Administrator revealed he forgot to change the date on the Facility Assessment. He could provide no evidence the Facility Assessment had been updated since 04/18/22. This deficiency is an incidental finding identified during the complaint investigation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to notify the responsible party, Power of Attorney (POA) or emergency contact of resident transfers to the hospital. This affected two (Residents #10 and #51) of three residents reviewed for notification. The facility census was 75. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 11/19/24. Diagnoses included quadriplegia, kidney disease and anemia. His sister was his emergency contact. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. He required set up help for eating and was dependent on staff for toileting, showering, dressing and hygiene. Review of the nursing progress note dated 06/03/25 at 6:45 A.M. revealed Resident #10 was admitted to the hospital due to a urinary tract infection. There was no documented evidence Resident #10's responsible party, POA or emergency contact was notified. Interview on 06/11/25…

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 send information to the hospital regarding resident health status upon transfer. This affected two (Residents #10 and #51) of three residents reviewed for hospitalizations. The facility census was 75. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 11/19/24. Diagnoses included quadriplegia, kidney disease and anemia. His sister was his emergency contact. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. He required set up help for eating and was dependent on staff for toileting, showering, dressing and hygiene. Review of the nursing progress note dated 06/03/25 at 6:45 A.M. revealed Resident #10 was admitted to the hospital due to a urinary tract infection. 2. Review of the medical record for Resident #51 revealed an admission date of 05/22/23. Diagnoses included Alzheimer's disease, kidney disease, anemia, depression and high…

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, resident interview and facility policy review, the facility failed to ensure residents received baths or showers per resident preference. This affected three (Resident #35, Resident #67, and Resident #69) out of six residents reviewed for activities of daily living (ADL) care. Findings include: 1. Resident #69 was admitted to the facility on [DATE] with diagnoses including dysphasia (a language disorder that affects a person's ability to speak following cerebrovascular disease (stroke), aphasia (a disorder that impacts ability to speak, understand, read, or write) following cerebrovascular disease (stroke), and contracture (deformities caused by tightening or shortening of muscles) of arms. Interview with Resident #69 and family on 06/10/25 at 10:33 A.M. revealed the resident does not bathing per their preferred method or frequency. Resident #69 and family noted their preferred bathing method is a tub bath. Resident #69's family indicated they have voiced concerns 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, record review and facility policy review, the facility failed to ensure physician orders to prevent skin breakdown were being followed. This affected one resident (Resident #9) out of three residents that were sampled for skin breakdown. The facility census was 75. Findings include: Resident #9 was admitted to the facility on [DATE]. Diagnoses included encounter for palliative care, cerebral atherosclerosis (narrowing of the arteries supplying blood to the brain from fat build up), vascular dementia, chronic obstructive pulmonary disease, and atherosclerotic heart disease (a narrowing of the arteries supplying blood to the heart from fat build up). Review of the care plan revealed on 07/12/24 Resident #9 had potential for pressure ulcer development and or alteration in skin integrity related to decreased mobility and fragile skin and an intervention to reposition on rounds and as needed. Review of the Minimum Data Set (MDS) assessment noted the following: Section C dated 04/10/25…

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 falls were thoroughly investigated. This affected two (Residents #22 and #51) of three residents reviewed for falls. The facility census was 75. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/18/25. Diagnoses included diabetes, heart disease, high cholesterol, anxiety, depression and chronic back pain. Review of the fall risk assessment dated [DATE] revealed Resident #22 was at risk for falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. She required set up help for eating, oral and personal hygiene and partial to moderate assistance for toileting. Review of the care plan dated 04/21/25 revealed Resident #22 was at risk for falls due to impaired safety awareness and age-related weakness. Interventions included anticipating the residents' needs, ensuring the call light was within reach and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the facility Self-Reported Incidents (SRIs), review of the facility investigation, and facility policy review, the facility failed to ensure thorough investigations were completed regarding diversion of narcotics and a resident-to-resident altercation. The facility also failed to ensure preventative and corrective measures were in place. This affected three residents (# 11, #61 and #72) of four residents who were investigated for abuse and misappropriation. The facility census was 82. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 04/08/24 with diagnoses including kidney disease stage three, retention of urine, acute chronic respiratory failure, chronic obstructive pulmonary disease, anxiety, and other seizures. Significant orders included admit to hospice with a diagnosis of congestive heart failure dated 06/13/24, check fentanyl patch (opioid pain medication) placement every shift, morphine sulfate oral…

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 there was a registered nurse (RN) on duty for at least eight consecutive hours, seven days a week as required. This had the potential to affect all 80 residents. The facility census was 80. Findings include: Review of the staff schedule for 08/04/24 revealed there was no RN scheduled in the building for first, second or third shift. Review of the facility Daily Staffing Sheet dated 08/04/24 revealed no ancillary or licensed registered nurse was scheduled 08/04/24 and review of employee time card punch in and out for 08/04/24 revealed nine licensed practical nurses (LPN) punched in and out on 08/04/24, twenty state tested nurse aids (STNA) punched in and out on 08/04/24 and one registered nurse (RN) punched in at 10:54 P.M. on 08/04/24 and punched out at 7:35 A.M. on 08/05/24. Interview on 08/19/24 at 10:50 A.M. with Staffing Coordinator #560 confirmed the schedule did not have any RN listed at least eight hours a day on 08/04/24. Interview on 08/20/24 at 11:02 A.M. with the Director of Nursing (DON ) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) manual, and interview, the facility failed to accurately code MDS assessments for five residents (#5, #11, #51, #71 and #73) of seven residents reviewed for resident assessments. The facility census was 80. Findings Include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, chronic obstructive pulmonary disease (COPD), seizures, heart disease, gastric reflux, generalized anxiety disorder, and vascular dementia without behavioral disturbance. Review of the physician's orders for Resident #5 revealed she was admitted to hospice upon admission [DATE]) with a diagnosis of end stage cerebral atherosclerosis. Review of the annual MDS 3.0 comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Section J Health Conditions revealed Resident #5 did not have a life expectancy of less…

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 maintain Resident #36's right to a dignified existence. This affected one resident (Resident #36) of the three residents reviewed for dignity. The facility census was 80. Findings include: Review of the medical record revealed Resident #36 was admitted [DATE] with diagnoses including memory deficit, morbid obesity, hypertensive congestive heart failure, and major depression. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition and was always incontinent of urine and frequently incontinent of bowel. Review of the physician order dated 02/02/23 for Resident #36 revealed an order for Lasix (a diuretic) 40 milligrams by mouth daily. Interview on 08/20/24 at 9:00 A.M. with Licensed Practical Nurse (LPN) #513 revealed Resident #36 urinated frequently due to being on a diuretic and even with frequent incontinence care every two hours, she was frequently wet with urine which caused a strong odor 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 Resident #37 was provided adequate assistance during ambulation to prevent a fall and that fall risk evaluations/assessments were completed at least quarterly. This affected one resident (#37) of three residents reviewed for falls. The facility census was 80. Findings include: Review of the medical record for Resident #37 revealed an admission date of 11/30/21 with diagnoses including dementia, major depression, history of falling, hypertension and anxiety. Review of physical therapy Discharge summary dated [DATE] revealed Resident #37 was able to ambulate with a front wheeled walker 100 feet with minimum assistance. Review of the Minimum Data Set ( MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #37 had impaired cognition, and required maximum assistance by staff to walk 10 feet and to walk 50 feet and turn twice. She also required maximum assistance to come to a standing position from sitting and transfer from chair to bed. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to maintain sufficient nursing services staff to meet the total care needs of residents according to their plan of care. This affected six residents (#4, #10, #32, #44, #72 and #79) and had the potential to affect all 78 residents residing in the facility. Findings include: Review of the Facility Assessment (dated 05/16/24) revealed the average daily census at the facility was 85. On page three and four of the assessment, the staffing plan was outlined and indicated to meet the acuity needs of the residents, the licensed nurses and State Tested Nursing Assistants (STNA) would provide a range of 3.28 to 4.78 hours of direct resident care per resident per day. Interview on 07/01/24 at 3:22 P.M. with State Tested Nursing Assistant (STNA) #808 revealed staff were unable to complete showers due to the facility getting rid of the shower aides. She stated residents might get bed baths, but they do not get showers. STNA #808 stated the facility 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, record review and interview, the facility administration did not ensure proper management of all resources for the highest practicable wellbeing of all residents which included failure to eradicate bed bugs, failure to ensure sufficient nursing staff to meet the resident's acuity needs, and failure to ensure resident rooms were maintained in a manner to protect the resident right to a safe, clean, comfortable environment. This had the potential to affect all 78 residents living in the facility. The facility census was 78. Findings include: Review of the undated job description for the Administrator revealed it was the essential function of the Administrator to enforce implementation of policies and procedures, supervise all department supervisors and administrative staff, assume responsibility with department supervisors to ensure adequate staffing, and establish systems to ensure compliance with all state, federal and local regulations. Review of the undated job description for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, shower schedule review, review of facility policy and staff and resident interview, the facility failed to ensure residents received showers per schedule or preference. This affected six Residents (#4, #10, #32, #44, #72 and #79) out of six Residents reviewed for showers. The facility census was 78. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 12/04/23. Diagnoses included major depressive disorder, generalized anxiety, chronic pain, hypertension, unspecified intellectual disabilities, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/2024, revealed Resident #4 to have intact cognition. He was assessed to be independent for most of their activities of daily living (ADL). He was assessed to need partial assistance by staff for personal hygiene and showers. Review of Resident #4's plan of care initiated on 03/05/24, revealed the resident preferred not to take a shower and stated he…

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, maintenance log review, medical record reviews, and staff and resident interviews the facility failed to ensure the walls in the resident rooms for Resident #1 and Resident #79 were in good repair. This affected two residents (Residents #1 and Resident #79) of eleven residents reviewed for physical environment. The facility census was 78. Findings include: 1.Review of the medical record for Resident #1 revealed an admission date of 04/26/24. The diagnoses included hypertensive urgency, chronic kidney disease, acute kidney failure, atherosclerotic heart disease, history of blood clot to lower extremities, disease of pancreas, and cholelithiasis without obstruction. Review of Resident #1's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had slight cognitive impairment. She required set up or clean up assistance with eating, she was supervision or touching assistance with oral hygiene, toileting, dressing, and bed mobility. She required partial 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, staff and resident interviews, record review and review of exterminator invoices the facility failed to maintain an effective pest control program for bed bugs. This affected one resident (Resident #4) of eleven residents reviewed for physical environment and had the potential to affect the additional 77 residents residing in the facility. The facility census was 78. Findings include: Review of the medical record for Resident #4 revealed an admission date of 12/04/23. Diagnoses included rash and other nonspecific skin eruption, major depressive disorder, generalized anxiety, hypertension, atrial fibrillation, and hypothyroidism. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. He was independent with eating, oral hygiene, toileting hygiene, dressing, and bed mobility. Resident #4 required partial assistance for showers and personal hygiene. Review of Resident #4's physician orders dated 06/03/24 revealed 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, interview and policy review, the facility failed to maintain a sanitary kitchen to prepare food in a manner to prevent contamination and food borne illness. This had the potential to affect 80 residents who receive food from the kitchen. The facility identified zero residents who did not eat by mouth. The facility census was 80. Findings include: On 05/13/24 at 8:15 A.M. a tour of the kitchen revealed a floor with built up dirt and debris in the dry storage area underneath the shelves. There was a half of a five-pound bag of macaroni opened and unlabeled, a quarter bag of shell macaroni opened and unlabeled. There was cornstarch in a 20-gallon lidded receptacle with a pan in it for scooping. The three-sink sanitation station had two containers of Hydrion strips (test strips to test the chemical levels for proper sanitization) with expiration dates of 07/01/20 and 05/31/19. The standup refrigerator located in the kitchen revealed one half of a five-pound brick of queso cheese that was opened and unlabeled. There was a 500-milliliter bottle of Pepsi 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 interviews, policy review, and review of the facility's investigation notes, the facility failed to ensure resident medications were not misappropriated. This affected two current residents (Residents #20 and #33) and two former residents (Residents #234 and #332) who resided on the one-hundred hall and had the potential to affect seven additional residents ( #26, #50, #54, #59, #67, #68, and #79) the facility identified as receiving controlled substances from the one hundred medication cart. The facility census was 80. Findings include: 1. Review of the medical record for Resident #20 revealed an initial admission date of 03/11/24 and a facility re-entry date of 04/26/24 with diagnoses including non-ST elevation myocardial infarction, heart failure, stage three pressure ulcer of the sacral region, morbid obesity, chronic obstructive pulmonary disease (COPD), cardiomyopathy, and osteoarthritis of the right hip. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility policy review, and review of the Ohio Department of Health (ODH) facility self-reported incidents (SRIs), the facility failed to file an SRI report related to allegations of misappropriation affecting four residents (Residents #20 and #33 and Former Residents #234, and #332) out of five residents reviewed for misappropriation. The facility census was 80. Findings include: 1. Review of the medical record for Resident #20 revealed an initial admission date of 03/11/24 and a facility re-entry date of 04/26/24 with diagnoses including non-ST elevation myocardial infarction, heart failure, stage three pressure ulcer of the sacral region, morbid obesity, chronic obstructive pulmonary disease (COPD), cardiomyopathy, and osteoarthritis of the right hip. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition, frequently experienced pain that interfered with sleep and participation in day-to-day activities for which…

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, interviews, record reviews, review of the memorandum from the Department of Health & Human Services and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure proper infection control practices were followed for Resident #14, #27, #41, #53, #69 and #78 who required enhanced barrier precautions (EBP) and Resident #55 who required blood glucose monitoring. This affected seven residents (#14, #27, #53,#69, #55 and #78) out of 80 residents observed for infection control. The facility census was 80. Findings include: 1. Observation on 05/13/24 at 10:23 A.M. of Resident #27 in the resident room revealed Resident #27 had an indwelling urinary cathetar. There was personal protective equipment (PPE) available in a hanging storage unit over the door and a unit to the left of the entrance door which contained PPE. Containers for used PPE were located outside of the room to the right of the entrance door. There was no visible sign to denote the type of transmission-based precaution (TBP) required. Interview with Activity…

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, medical record review, and review of facility policy, the facility failed to ensure the resident's right to self-administer medications was clinically appropriate. This affected one Resident (#78) of eight residents reviewed for medication administration. The facility census was 80. Findings include: Review of the medical record for Resident #78 revealed an admission date of 01/22/24 with diagnoses including type two diabetes mellitus, cellulitis of the right nd left lower limbs, chronic pressure ulcers with necrosis of the muscle of both feet, gangrene, atrial fibrillation, hypertension, and asthma. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #78 had intact cognition and had asthma. Review of the physician orders revealed an order dated 01/22/24 for albuterol sulfate inhalation aerosol solution 108 (90 base) micrograms (mcg) per actuation, two puffs inhaled orally every six hours as needed for shortness of breath (SOB) related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and policy review the facility failed to ensure resident choices related to advanced directives were honored. This affected one resident (Resident #78) of two reviewed for advanced directives. The facility census was 80. Findings include: Review of the medical record for Resident #78 revealed an admission date of [DATE] with diagnoses including type two diabetes mellitus, cellulitis of the right nd left lower limbs, chronic pressure ulcers with necrosis of the muscle of both feet, gangrene, atrial fibrillation, hypertension, and asthma. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on [DATE] revealed Resident #78 had intact cognition and was independent with personal care. Review of the physician orders revealed an active order dated [DATE] designating Resident #78 as a full code. Review of the progress note dated [DATE] revealed the Social Services Designee (SSD) discussed advanced directives with Resident #78 on this date. During 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 change nasal cannula oxygen tubing in a timely manner. This affected one resident (#39) of one resident reviewed for oxygen use. The facility identified 18 residents (#2, #14, #21, #22, #24, #27, #30, #33, #39, #41, #50, #51, #52, #60, #63, #67, #76 and #132) utilizing oxygen. The facility census was 80. Findings include: A review of medical records for Resident #39 revealed a date of admission of 02/13/23. Significant diagnoses included chronic obstructive pulmonary disease and heart failure. Significant orders included, change oxygen tubing weekly (Tuesdays) and oxygen at two liters per minute per nasal cannula (a tubing system with two prongs inserted in the nose for oxygen delivery) as needed for shortness of breath. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment. A care plan dated 04/12/24 revealed Resident #39 was at risk for ineffective breathing related to heart…

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, interview, review of Authorization for Release of Specialized Privileged Information and facility policy review, the facility failed to provide copies of the medical record to Resident #8's representative. This affected one resident (#8) of one resident reviewed for medical record requests. The facility census was 89. Findings include: Review of the medical record for Resident #8 revealed an admission date of 07/19/22. Medical diagnoses included cerebral atherosclerosis, chronic obstructive pulmonary disease, generalized anxiety disorder, and vascular dementia. Review of the emergency contacts for Resident #8 revealed the resident's daughter was the only emergency contact listed. Review of the medical record did not contain documented evidence that the facility processed a request for medical records to be received by Resident #8's representative. Interview on 04/02/24 at 10:51 P.M. with Resident #8's representative revealed she made a verbal request to the Administrator for release of medical records related to dental services provided at the facility.…

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 self-reported incident (SRI) and facility policy review, the facility failed to thoroughly investigate an allegation of sexual abuse as required. This affected one resident (#47) of three residents reviewed for abuse. The facility census was 89. Findings include: Review of the medical record for Resident #47 revealed an admission date of 03/04/24. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, epilepsy, essential hypertension, and generalized anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired and had hallucinations. Review of SRI #245110 dated 03/11/24 revealed Resident #47 alleged she had been raped. She was interviewed by three different staff members on three different occasions, all findings were inconclusive. Further review of SRI #245110 revealed no documented evidence of a skin assessment for Resident #47 and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident #64 was provided showers according to his needs and preferences. This affected one resident (Resident #64) out of eight residents reviewed for showers. The facility census was 89. Findings include: Review of Resident #64's medical record revealed an admission date of 02/05/23 with diagnoses including hypertension, chronic kidney disease stage one, hemiplegia following a cerebrovascular accident, obstructive sleep apnea, and aphagia. Review of Resident #64's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and was dependent on two staff members for all Activities of Daily Living (ADLs) including showering. Review of the facility Shower Schedule revealed Resident #64 was to receive showers on Monday and Thursday each week. Review of Resident #64's shower sheets revealed at no point did he receive a shower in the shower room. He had only received bed baths which were not his preference.…

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, Self-Reported Incident (SRI) tracking number (#)240778 review, facility investigation review, Police Report #23-23497 review, and review of the abuse policy the facility failed to ensure Resident #6 was free from staff to resident abuse. This affected one resident (#6) out of six residents reviewed for abuse. The facility census was 86. Findings included: Review of the medical record for Resident #6 revealed an admission date of 07/08/23 with diagnoses including amyotrophic lateral sclerosis (ALS), Parkinson's disease, hypertension, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition as his Brief Interview for Mental Status (BIMS) score was a 15 out of 15. He had no behaviors documented. He required extensive assistance from two staff with bed mobility and transfers. He required total assistance from one staff with toileting. He was unable to ambulate. He was occasionally incontinent of urine but always…

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, personnel file review, interview, and review of the Ohio Board of Nursing website the facility failed to ensure medications were administered by a licensed nurse. This affected 42 residents (#2, #6, #10, #12, #13, #14, #15, #16, #17, #18, #20, #23, #25, #27, #30, #31, #35, #36, #37, #40, #42, #44, #45, #46, #47, #51, #53, #55, #57, #58, #60, #63, #64, #65, #69, #70, #73, #74, #75, #76, #77, and #78). The facility census was 82. Findings include: An interview with the Administrator on [DATE] at 8:47 A.M. revealed Registered Nurse (RN) #447 was terminated on [DATE] for not having a valid nursing license. The Administrator stated that RN #447 had worked over the weekend of [DATE] to [DATE]. The Administrator further stated that RN #447's nursing license expired on [DATE]. Review of RN #447's nursing license on the Ohio Board of Nursing website revealed RN #477's nursing license expired on [DATE]. Review of employee file for RN #477 revealed, on [DATE] RN #477 was terminated from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #41's physician was notified timely on radiographic findings. This affected one (Resident #41) of four residents reviewed for notification. The facility census was 85. Findings include: Review of the medical record for Resident #41 revealed an admission date of 07/11/22 with diagnoses including chronic kidney disease, diabetes mellitus and absence of left leg below the knee. Review of the fall investigation dated 08/26/23 at 6:00 A.M. revealed Resident #41 updated the nurse that his left wrist, hand and forearm had discomfort. He stated during a transfer prior to dialysis that morning, the mechanical hoyer lift was mistakenly released too quickly and he ended up on the floor. Resident #41's physician was updated, and an X-ray was ordered. The staff were educated on proper mechanical hoyer lift use. Review of the nursing progress note dated 08/26/23 at 12:05 P.M. revealed Registered Nurse (RN) #205 was updated upon Resident #41's return…

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 staff properly transferred Resident #41 with a mechanical hoyer lift and failed to ensure a thorough investigation was completed following Resident #41's fall from the mechanical hoyer lift. This affected one (Resident #41) of three residents reviewed for falls and mechanical lift transfers. The facility census was 85. Findings include: Review of the medical record for Resident #41 revealed an admission date of 07/11/22 with diagnoses including chronic kidney disease, diabetes mellitus and absence of left leg below the knee. Review of Resident #41's care plan dated 07/26/22 revealed he was at risk for falls related to left below the knee amputation and weakness. Interventions included, but not limited to, to transfer him by two staff members with a mechanical lift for all transfers. Review of the physician's order dated 07/27/22 revealed Resident #41 was to be transferred with a mechanical lift with two staff for all transfers. Review of the fall investigation dated 08/26/23 at 6:00 A.M. revealed Resident #41…

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 #86 had oxygen orders from the physician corresponding to the oxygen she was utilizing. This affected one (Resident #86) of three residents reviewed for respiratory care. The facility census was 85. Findings include: Review of the medical record for Resident #86 revealed an admission date of 08/21/23 with diagnoses including chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure and pneumonia. She was discharged back to the hospital on [DATE]. Review of Resident #86's physician's orders dated 08/21/23 revealed an order for oxygen at two liters per minute per nasal cannula as needed for shortness of breath. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2023, revealed Resident #86 had an order for oxygen at two liters as needed but was not signed off as utilized by the nursing staff. Review of the nursing progress notes dated from 08/21/23 through…

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, facility policy and procedure review, and interview the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property as required. This had the potential to affect all 76 residents residing in the facility. Findings include: Review of the personnel file for Hospitality Aide (HA) #471 revealed a hire date of 07/12/22. There was no printed evidence HA #471 was checked against the NAR prior to the first day of work/hire. Review of the personnel file for Registered Nurse (RN) #496 revealed a hire date of 07/12/22. There was no printed evidence RN #496 was checked against the NAR prior to the first day of work/hire. Review of the personnel file for Licensed Practical Nurse (LPN) #443 revealed a hire date of 07/12/22. There was no printed evidence LPN #443 was checked against the NAR prior to the first day 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 interview, record review, and policy review the facility failed to ensure Resident #5's guardian was notified when she was sent to the hospital. This affected one (Resident #5) of three residents reviewed for hospitalizations (Residents #5, #55 and #70). The facility census was 76. Findings include: Review of the medical record revealed Resident #5 was admitted [DATE] with diagnoses including Alzheimer's disease with late onset, dementia with behavioral disturbance, congestive heart failure, and protein-calorie malnutrition. Resident #5 had a physician order dated 12/05/21 for enteral nourishment (tube feeding) Glucerna 1.2 continuous at 55 cubic centimeters (cc)cc/ hour (hr). Review of the Quarterly Minimum Data Summary (MDS) 3.0 assessment of 08/01/22 revealed Resident #5 was severely cognitively impaired, continuous altered level of consciousness, required total dependence of two staff, and received 51 percent (%) or more of her total calories received through parenteral or tube feeding. 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 interview and record review the facility failed to ensure Resident #71 was free of staff to resident verbal abuse. This affected one (Resident #71) of three residents (Residents #4, #17, and #71) reviewed for abuse. The facility census was 76. Findings included: Review of the closed medical record for Resident #71 revealed an admission date of 11/03/21 and discharge date of 08/18/22 to another facility. Diagnoses included quadriplegia from a previous gunshot injury, diabetes, and anxiety disorder. Review of the care plan dated 11/04/21 revealed Resident #71 had a deficit in activities of daily living self-performance related quadriplegia. Intervention included extensive assist of two staff with bathing, total dependence of two staff with a mechanical lift for transfers, praise all efforts at self-care. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #71 had intact cognition and had no behaviors documented. He required total dependence of two staff with bed…

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.