Washington Square Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Centers for Medicare and Medicaid services (CMS) memorandum QSO-24-08-NH, and review of facility policy, the facility failed to utilize enhanced barrier precautions (EBP) for Resident #54 during high contact resident care. This affected one resident (Resident #54) out of two residents observed for EBP. This had the potential to affect 27 residents (Residents #1, #3, #5, #9, #10, #19, #20, #21, #31, #34, #36, #39, #41, #43, #45, #44, #48, #53, #54, #56, #60, #61, #66, #67, #69 #70 and #73) identified by the facility on EBP.Findings include:Review of medical record for Resident #54 revealed an admission date of 12/31/20 and her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, chronic obstructive pulmonary disease, and pulmonary edema. Review of care plan dated 10/07/25 revealed Resident #54 required EBP due to a feeding tube (a flexible tube inserted in the stomach to provide fluids…

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 review of facility policy, the facility failed to report allegations of abuse to the state agency as required. This affected one (Resident #5) of three residents reviewed for abuse. The facility census was 67.Findings include:Review of Resident #5's medical records revealed an admission date of 07/18/22 with diagnoses including but not limited to cerebral infarction, hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, unspecified psychosis, unspecified anxiety disorder, malignant neoplasm of colon, altered mental status, hypertension (high blood pressure), need for assistance for personal care, muscle atrophy, type two diabetes and aphasia (acquired language disorder affecting communication).Review of the care plan revised on 02/28/26 revealed Resident #5 was dependent on staff…

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 the resident representative was immediately notified about a leg injury and failed to ensure proper notification to the representative of an outside medical appointment for Resident #5. This effected one resident ( Resident #5) of six residents ( #3, #5, #30, #31, #41,and #58) reviewed for change in condition. The facility census was 67.Findings include:Review of the medical record for Resident #5 revealed an admission date of 07/18/22 with diagnoses including but not limited to cerebral infarction, hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, unspecified psychosis, unspecified anxiety disorder, malignant neoplasm of colon, altered mental status, hypertension (high blood pressure), need for assistance for personal care, muscle atrophy, type two diabetes and aphasia (acquired language disorder…

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 witness statements, interviews and review of facility policy, the facility failed to ensure Resident #5 was free from verbal abuse by a staff member. This affected one resident (#5) out of three residents reviewed for abuse. The facility census was 67.Findings include:Review of Resident #5's medical records revealed an admission date of 07/18/22 with diagnoses including but not limited to cerebral infarction, hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, unspecified psychosis, unspecified anxiety disorder, malignant neoplasm of colon, altered mental status, hypertension (high blood pressure), need for assistance for personal care, muscle atrophy, type two diabetes and aphasia (acquired language disorder affecting communication). Review of the care plan revised on 02/28/26 revealed Resident #5 was dependent on staff for meeting…

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 review of facility policy the facility failed to coordinate transportation services that were resident centered following a surgical procedure for the highest practicable well-being for Resident #41, and failed to adequately monitor Resident #5 following a change in health status resulting in hospitalization. This affected two residents ( Resident #5 and #41 ) of five residents reviewed for quality of care . The facility census was 67.Findings include:Findings include: 1.Review of Resident #5's medical records revealed an admission date of 07/18/22. Diagnoses included hemiplegia with right side weakness, muscle weakness and need for personal care assistance. Review of the care plan revised 02/28/26 revealed Resident #5 had hemiplegia related to a stroke. Interventions included reposition as tolerated every two hours. Resident #5 had self-care deficits that included dressing, personal hygiene, eating, toileting and bathing. Resident #5 required extensive…

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 review of facility policy, the facility failed to ensure Resident #69 was free from a significant medication error. This affected one resident (#69) of three residents reviewed for medication administration. The facility census was 67. Findings include:Review of Resident #69's medical records revealed an admission date of 12/12/25. Diagnoses included diabetes, hypertension and difficulty walking. Review of care plan dated 03/11/26 revealed Resident #69 had diabetes. Interventions included administer diabetic medications as ordered, monitor/document/report signs and symptoms of hyperglycemia (high blood sugar) that included increased thirst.Review of physician orders for April 2026 included administer Humalog (fast acting insulin) subcutaneously per sliding scale before meals and at bedtime. If blood sugar 150 to 200 milligrams per deciliter (mg/dl) give two units, 201 to 250 give four units, 251 to 300 give six units, 301 to 350 give eight units, 351 to 400 give 10 units and if over 401 contact physician. Review of Medication…

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

Based on observation, interview and record review the facility failed to ensure accurate documentation of blood sugar values. This affected one resident (#69) of three residents reviewed for medication administration. The facility census was 67.Review of Resident #69's medical records revealed an admission date of 12/12/25. Diagnoses included diabetes, hypertension and difficulty walking. Review of care plan dated 03/11/26 revealed Resident #69 had diabetes. Interventions included administer diabetic medications as ordered, monitor/document/report signs and symptoms of hyperglycemia (high blood sugar) that included increased thirst.Review of physician orders for April 2026 included administer Humalog (fast acting insulin) subcutaneously per sliding scale before meals and at bedtime.Review of Medication Administration Record (MAR) revealed on 04/16/26 Licensed Practical Nurse (LPN) #614 documented Resident #69's blood sugar of 131 (normal range is 60-100). Resident #69's sliding scale indicated no insulin required for a blood sugar reading of less than 150.Review of Resident #69's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of personnel files and review of the facility corrective action, the facility failed to ensure that all nursing staff were competent and legally licensed to provide nursing care and services to residents. This had the potential to affect all residents residing in the facility. The facility census was 67.Findings include:Review of the Ohio Board of Nursing (OBN) document Order, Suspension of License, revealed on 01/22/26 Licensed Practical Nurse (LPN) #810's professional license was suspended due to narcotic diversion.Review of LPN #810's employee file revealed a hire date of 02/25/25 and a termination date of 02/25/26. There was no evidence in the file of a quarterly licensure verification completed by the facility on LPN #810's license.A confidential interview on 03/10/26 at 4:43 P.M. revealed concerns regarding LPN #810's professional license being suspended due to issues with narcotics and concern that LPN #810 continued to work without a license as a nurse providing nursing 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 record review, and interview the facility failed to demonstrate effective leadership of the overall facility operations to ensure each resident attained/maintained their highest practicable physical, mental, and psychosocial well-being. This affected five residents (#3, #28, #41, #43, and #68) and had the potential to affect all residents in the facility. The facility census was 67.Findings include:Review of the job description for the position of Administrator revealed it was signed by the facility Administrator on 09/13/24. The position summary included leading and directing the overall operation of the facility in accordance with resident needs, government regulations, and company policies to maintain quality of care for the residents while achieving the facility's business directives. Administrative duties included but were not limited to maintaining working knowledge and ensuring compliance with all governmental regulations, monitoring employee relations practices of key staff to ensure compliance…

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, facility records review and facility policy review, the facility failed to ensure the shower room on the [NAME] Unit was maintained in sanitary condition and good repair. This had the potential to affect all 37 (#1, #4, #7,#8, #9, #10, #12, #14, #17, #19, #21, #22, #25, #26, #27, #32, #34, #35, #38, #41, #42, #44, #46, #49, #50, #52, #53, #54, #56, #57, #58, #61, #62, #63, #64, #66, and #67) residents on the [NAME] Unit. The facility census was 67.Findings include:Observation on 03/10/26 at 1:30 P.M. of the [NAME] Unit shower room revealed the room was humid, and the ceiling vent did not turn on upon activation of the switch. The baseboard radiator was dented and rusty. Behind the toilet where the wall met the floor was a build-up of black substance for approximately 15 tiles, and each floor tile measured two inches by two inches. Upon entering the shower area, to the left above the shower head were approximately five to six black spots on the ceiling. At the bottom of the same…

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 ensure all residents were treated with respect and dignity. This affected one resident (Resident #68) out of 11 residents reviewed for resident rights. The facility census was 67.Findings include:Review of Resident #68's medical record revealed an admission date of 12/12/25. Diagnoses included hyperlipidemia, difficulty in walking, repeated falls, hypertension, type two diabetes, anxiety, depression and chronic kidney disease.Review of Resident #68's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, was able to make all needs know and required supervision with eating, assistance from staff with dressing, toileting, and self-propelled in his wheelchair.Interview on 03/24/26 at 11:30 A.M. with Resident #68 revealed on 03/20/26 at 9:30 A.M. he spoke with Certified Nursing Assistant (CNA) #819 and asked for his bed to be made and straighten up his room because his family 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, interview and review of facility policy the facility failed to ensure residents were free from misappropriation of narcotics. This affected three residents (Residents #38, #41 and #69) of four residents reviewed for misappropriation of narcotics. The facility census was 67.Findings include:1.Review of the medical record for Resident #38 revealed an admission date of 09/29/23 with diagnoses including gangrene, hyperlipidemia, hypertension, peripheral vascular disease (PVD), cellulitis, type two diabetes, acquired absence of left toes, and muscle weakness.Review of Resident #38's care plan, revised 07/22/25, revealed the resident had actual pain related to cellulitis in left lower extremity. Staff were to monitor and document for side effects of pain medication, observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls, report all occurrences to the physician. Additionally, staff were to monitor,…

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, review of the facility self-reported incident (SRI) and investigation, and policy review the facility failed to ensure allegations of misappropriation of narcotics were thoroughly investigated. This affected three residents (Residents #28, 41 and #69) out of four residents reviewed for misappropriation of narcotics. The facility census was 67.Findings include:Review of SRI 271810 reported to the Ohio Department of Health (ODH) on 03/06/26 at 7:40 P.M. by the facility Administrator revealed an allegation of misappropriation was being reported. The alleged perpetrator was Licensed Practical Nurse (LPN) #816 and three residents (#28, #41 and #69) were allegedly involved. A brief description included that residents reported increased pain requiring additional medication and an investigation was initiated to ensure medications were being given. The facility unsubstantiated that abuse/misappropriation had occurred based on inconclusive evidence that misappropriation had occurred.…

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 care conference meeting documents, resident and staff interview, and review of facility policy, the facility failed to ensure all minimum required members of the Interdisciplinary team were present during care plan meetings. This affected one resident (Resident #41) out of 11 residents reviewed for care plans. The facility census was 67.Findings include:Review of Resident #41's medical record revealed an admission date of 03/07/23. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), kidney stones, chronic kidney disease (CKD) stage three, viral hepatitis C, hypothyroidism, morbid obesity, mood disorder, bipolar disease, and anxiety.Review of Resident #41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition was independent with eating and required partial to moderate assistance with all other Activities of Daily Living (ADLs).Review of Resident #41's Care Conference meeting notes dated 03/03/26 revealed the only attendees…

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 facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #70) of 11 residents reviewed for medication administration. The facility census was 67.Findings include:Review of Resident #70's medical record revealed an admission date of 08/13/25 and a discharge date of 11/20/25. Diagnoses included chronic kidney disease stage four, depression, cerebral infarction, osteoarthritis, lower back pain, Alzheimer's disease, Post Traumatic Stress Disorder (PTSD), pressure ulcer of left heel stage three, and pneumonitis due to inhalation of food and vomit.Review of Resident #70's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and was dependent on staff for all Activities of Daily Living (ADLs) including medication administration.Review of Resident #70's physician orders dated November 2025 revealed the resident was to receive Fentanyl Transdermal…

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, review of the facility self-reported incident, and review of facility policy, the facility failed to ensure complete and accurate medical records were maintained for Resident #3 and Resident #43. This affected two residents (Resident #3 and Resident #43) out of 11 residents reviewed for resident records. The facility census was 67.Findings include:Review of the facility self-reported incident dated 02/28/26 revealed staff reported an allegation of physical abuse between Resident #3 and Resident #43. Details included Resident #3 placing his hands in the vicinity near Resident #43's neck, however, it was not seen by staff or anyone. The residents were separated, assessed to be free from injury, placed on 15-minute checks, and a room change was implemented to further separate the residents. The facility unsubstantiated that abuse had occurred.Review of the medical record for Resident #3 revealed an admission date of 02/05/26 with diagnoses including schizoaffective disorder,…

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 and record review the facility failed to ensure residents were treated with dignity and respect. This affected one Resident (Resident #19) out of three residents reviewed for dignity and respect. The facility census was 60.Findings include:Review of the medical record for Resident #19 revealed an admission date of 08/08/23 with diagnoses including type two diabetes, cellulitis, depression, morbid obesity, malignant neoplasm or endometrium, need for assistance with personal care, and muscle weakness.Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required setup to clean up assistance with eating, partial to moderate assistance with oral and personal hygiene, and substantial to maximal assistance with toileting and showering.Review of Resident #19's care plan, date initiated 08/21/23, revealed Resident #19 had a problem with psychosocial wellbeing related to a diagnosis of depression. Interventions included to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure a comprehensive, person-centered care plan was developed to address individual needs and preferences related to insulin administration for Resident #19. This affected one resident (Resident #19) of 11 residents reviewed for care plans. The facility census was 60. Findings include:Review of the medical record for Resident #19 revealed an admission date of 08/08/23 and a pertinent diagnosis of type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was cognitively intact and used insulin seven out of seven days. Review of the care plan, date initiated 08/21/23 and last revised on 05/01/25, revealed there was no care plan for the prescribed insulin, nor measurable goals or interventions pertaining to the use of insulin. There was nothing to indicate in the care plan that Resident #19 had preferences for certain nurses to not administer her insulin. Review of the physician orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure one resident (Resident #19) received her insulin as ordered. This affected one resident (Resident #19) of three residents reviewed for medication administration. The facility census was 60. Findings include:Review of the medical record for Resident #19 revealed an admission date of 08/08/23 and a pertinent diagnosis of type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was cognitively intact and used insulin seven out of seven days. Review of the care plan, date initiated 08/21/23 and last revised on 05/01/25, revealed there was no care plan for insulin administration. On 02/29/24 a care plan was initiated for Resident #19 regarding resistance to care including refusing medications and insulin. The interventions included allow resident to make decisions about treatment, educate on possible outcomes of not complying, if possible negotiate a time for treatments…

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 did not ensure lab results were timely reported to the physician. This affected one resident (#19) out of three residents reviewed for lab services. The facility census was 60. Findings include:Review of the medical record for Resident #19 revealed an admission date of 08/08/23. Diagnoses included diabetes, morbid obesity, anemia, depression, kidney disease and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was cognitively intact and used insulin seven out of seven days.Review of the physicians orders for July 2025 revealed an order for Resident #19 to have her A1C (a blood test that provides an estimate of a person's average blood sugar levels over the past two to three months) drawn on admission then every six months.Review of the care plan dated 05/09/25 revealed resident #19 had a nutritional problem of morbid obesity. Interventions included administering medications as ordered, explaining 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 and interview the facility did not ensure a complete and accurate medical record for Resident #19. This affected one resident (Resident #19) out of 11 residents reviewed for complete and accurate medical record. The facility census was 60.Findings include:Review of the medical record for Resident #19 revealed an admission date of 08/08/23 and a pertinent diagnosis of type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was cognitively intact and used insulin seven out of seven days. Review of the physician orders for July 2025 for Resident #19 revealed an order for insulin glargine subcutaneous 100 units per milliliter (ml) 38 units at bedtime. Review of the Medication Administration Record (MAR) for June 2025 revealed no evidence insulin glargine 100ML 38 units at bedtime was administered to Resident #19 on 06/04/25 or 06/24/25, as the MAR on these dates for this medication was left blank and void of nurse initials…

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 a safe, functional and comfortable environment for residents, staff and the public. This had the potential to affect 14 residents (Residents #2, #5, #12, #15, #21, #25, #27, #32, #42, #47, #48, #49, #53 and #57) who resided on the [NAME] unit, out of 60 residents observed for physical environment. The facility census was 60.Findings include:An interview on 07/08/25 at 1:15 P.M. with Ombudsman #190 and Ombudsman #191 revealed Ombudsman #191 was present in the facility on 06/18/25 when there was a heavy rain storm and rain water was coming in under the exit door on the [NAME] unit in the hallway by Resident #21 and #27's room. Ombudsman #191 brought it to the attention of the Maintenance Director who verified that during heavy rain water flowed in under the exit door on that unit. Ombudsman #190 and Ombudsman #191 both confirmed they notified the Administrator and had a phone conversation with the Regional Director of Operations (RDO)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, the facility failed to ensure medications were disposed of timely when discontinued or a resident was discharged . This had the potential to affect all 29 residents residing on the [NAME] Unit (Residents #2, #3, #4, #6, #8, #16, #19, #20, #26, #31, #35, #36, #38, #39, #40, #41, #42, #43, #45, #46, #47, #49, #52, #62, #116, #117, #118, #120 and #267). The facility census was 62. Findings include: Observation on 04/21/25 at 1:48 P.M. of the medication storage room on the [NAME] Unit with Licensed Practical Nurse (LPN) #338 revealed the room had resident medication cards, pill bottles and boxes of aerosol medications piled on shelves, on the floor, in baskets on the floor and in bags. There were four white pills in a plastic cup sitting on the shelf. LPN #338 verified she was unsure what pills were in the cup and who they belonged to. LPN #338 stated staff were to fill out a pharmacy paper and send the medications back to pharmacy 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, interview and review of facility policy, the facility failed to maintain a safe, functional, sanitary and comfortable environment. This had the potential to affect all 29 residents (Residents #2, #3, #4, #6, #8, #16, #19, #20, #26, #31, #35, #36, #38, #39, #40, #41, #42, #43, #45, #46, #47, #49, #52, #62, #116, #117, #118, #120 and #267) who resided on the [NAME] Unit, one resident ( Resident #1) on the [NAME] Unit, and an additional 13 residents (Residents 9, #11, #27, #23, #48, #22, #29, #17, #37, #28, #59, #53, #62) the facility identified as residents who smoke. The facility census was 62. Findings include: Observation was conducted on 04/22/25 from 3:45 P.M. to 4:01 P.M. with Maintenance Director (MD) #314 of the facility physical environment and the following concerns were identified and verified with MD #314 at the time of the observations: • On theWashington Unit hallway there was a solid, dark brown water stain on the ceiling which MD #314 stated it was caused from a water leak. •…

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 did not ensure a comprehensive care plan was developed to include the need for Enhanced Barrier Precautions (EBP) for Resident #267. This affected one resident (#267) of 25 residents reviewed for care plans. The facility census was 62. Findings include: Review of the medical record for Resident #267 revealed an admission date of 04/10/25 with diagnosis including malignant neoplasm of the mouth, malignant neoplasm of the head, dysphagia, severe protein calorie malnutrition, bacteremia, attention to gastrostomy (a surgical procedure used to insert a tube through the abdomen and into the stomach), and cachexia. Review of Resident #267 Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and had a feeding (gastrostomy) tube. Review of the physician order dated 04/14/25 revealed the feeding tube site needed cleansed with soap and water and apply dry dressing every night shift. There was no order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and review of facility policy the facility failed to ensure enhanced barrier precautions (EBP) were implemented for Resident #216 and Resident #267. This affected two residents (#216 and #267) of 21 residents (Resident #36, #35, #45, #46, #34, #6, #47, #40, #38 #2, #51, #7,#36, #48, #5, #32, #33, #53, #118, #216 and #267 ) the facility identified as requiring EBP. The facility census was 62. Findings include: 1. Review of Resident #216's medical record revealed a readmission date of 10/24/24 with diagnoses including intracranial hemorrhage, malignant neoplasm of prostate, type two diabetes, altered mental status, chronic obstructive pulmonary disease, and pneumonia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #216's cognition was intact, and unhealed pressure ulcers were present upon admission/re-entry. Review of Resident #216's physician orders for April 2025 revealed no active orders for EBP. There was an order with a start…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of Self-Reported Incident (SRI) tracking number (#)240669, review of a personnel file, and facility policy review the facility failed to prevent misappropriation of a narcotic medication for Resident #56. This affected one resident (#56) of one resident reviewed for misappropriation of property. The facility census was 60. Findings include: Review of the medical record for Resident #56 revealed an admission date of 12/07/17. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, chronic obstructive pulmonary disease, vascular dementia, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated moderate cognitive impairment. Review of the progress notes from October 2023 to November 2023 revealed due to aphasia Resident #56 had difficulty…

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, staff interviews, record review, and facility policy review the facility failed to provide adequate supervision to prevent elopement of Resident #10. This affected one resident (#10) of one resident reviewed for elopement. The facility census was 61. Finding include: Review of Resident #10's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, vertigo, heart failure, psychotic disorder, schizophrenia, muscle weakness, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition, no wandering behaviors, and could wheel 150 feet in a wheelchair. The resident required supervision for activities of daily living and with movement off the unit. Review of the elopement risk assessment dated [DATE] revealed Resident #10 was at a low risk for wandering. Review of Resident #10's care plan dated 02/13/23 revealed the resident was care planned for impaired thought process. 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 observation and staff interviews, the facility did not ensure the facility menus were followed and were reviewed by the facility registered dietitian as required for nutritional adequacy. The facility identified all 68 residents' received meals from the kitchen. Findings include: Interview on 08/23/23 at 10:25 A.M. with Registered Nurse (RN) #357 revealed menus were not being followed. Interview on 08/23/23 at 2:44 P.M. with Dietary Aide #328 and Dietary Cook/Aide #358 revealed menu items had to be frequently substituted, since menu items were not available in the facility. Review of facility menu for 08/23/23 lunch revealed roast pork, roasted potatoes, vegetable blend, and cheesecake were to be served. Review of spreadsheets for facility menus from 08/20/23 to 08/26/23 revealed there were no spreadsheets. Observation of tray line on 08/23/23 from 12:01 P.M. to 1:27 P.M. revealed residents were served pork loin, cauliflower, mashed potatoes, and cheesecake. At the time of observation, Dietary Director…

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

Based on observations, interviews, and record review the facility failed to take into consideration the preferences of residents and did not ensure residents on a renal diet and carbohydrate consistent diet received a diet that met their special dietary needs. The facility identified two residents (#20 and #39) on a renal diet and 17 residents (#8, #10, #11, #16, #21, #23, #25, #32, #38, #50, #51, #56, #60, #61, #62, #65, and #68) on a carbohydrate consistent diet. This had the potential to affect all 68 residents who received meals from the kitchen. Findings include: Interview on 08/23/23 at 9:35 A.M. with Dietary Director #322 revealed she made the menus and there were no spreadsheets for the menus. Interview on 08/23/23 at 10:20 A.M. with Resident #36 revealed she had been asked in the past what she wanted for the meal, but currently she wasn't being asked. Interview on 08/23/23 at 10:34 A.M. with Resident #61 revealed he was a diabetic and he didn't feel the facility was following a diabetic diet, since he was getting two Danishes at a time at breakfast. Interview on 08/23/23 at…

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

Based on observation and staff and resident interviews, the facility failed to ensure competent dietary support staff to ensure residents on renal diets and carbohydrate consistent diets received meals per the physician's orders. The facility identified two residents (#20 and #39) on a renal diet and 17 residents (#8, #10, #11, #16, #21, #23, #25, #32, #38, #50, #51, #56, #60, #61, #62, #65, and #68) on a carbohydrate consistent diet. The facility census was 68. Findings include: Interview on 08/23/23 at 9:35 A.M. with Dietary Director #322 revealed she made the menus and there were no spreadsheets for the menus. Interview on 08/23/23 at 10:34 A.M. with Resident #61 revealed he was a diabetic and he didn't feel the facility was following a diabetic diet, since he was getting two Danishes at a time at breakfast. Observation on 08/23/23 of tray line from 12:40 P.M. to 1:27 P.M. revealed there was no spreadsheets, and the residents on a carbohydrate consistent diet received the same diet as the regular diet, which consisted of pork loin with gravy, mashed potatoes, cauliflower, 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 observations, record review, and interview, the facility failed to ensure menus included a variety of food and failed to ensure menus and recipes were followed. This affected all residents except Resident #35 who received nothing by mouth. The facility census was 65. Finding include: 1. Review of the menu for week two revealed chicken for dinner on Sunday and Monday and for lunch on Tuesday. Review of the renal menu for week two revealed turkey sandwiches for lunch on Sunday and Thursday and for dinner on Tuesday and Wednesday. Interview on 12/06/22 at 12:00 P.M. with Dietary Manager (DM) #451 verified the main menu had chicken for three consecutive days. DM #451 stated that was why she switched today's lunch to Sloppy joes. DM #451 verified the renal menu had turkey sandwiches repeatedly on the menu. DM #451 stated she had heard residents complain of the lack of variety on the menu. 2. Observation of tray line on 12/06/22 at 12:08 P.M. revealed the regular Sloppy [NAME] was served using a green handled…

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, policy and procedure review, and review of the Centers for Disease Control guidelines, the facility failed to ensure all employees were administered a baseline Tuberculosis (TB) test on hire. This had the potential to affect all 65 residents in the facility. Findings include: Review of the facility's TB risk assessment revealed the facility was a low risk classification. Review of the personnel file for the Administrator revealed a hire date of 08/10/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Dietary Manager #451 revealed a hire date of 06/21/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Admissions Director #445 revealed a hire date of 04/25/22. There was no evidence a tuberculosis test was administered prior to starting work. Review of the personnel file for Social Service Designee #438 revealed a hire date of 09/23/22. There was no evidence a tuberculosis test was administered prior to starting…

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 observation and interview the facility failed to maintain comfortable temperature levels. This affected five (Residents #13, #17, #28, #31 and #44) of 15 residents whose rooms were observed for comfortable temperatures. Findings include: Interviews and observations on 12/04/22 from 10:49 A.M. to 11:25 A.M. with Residents #13, #17, #28, #31 and #44 revealed their rooms were cold. Resident #13 was observed lying in bed under the blankets wearing a hoodie and long sleeve shirt. Resident #17 was observed wearing a winter hat, coat and gloves seated in a wheelchair. Resident #28 was observed sitting in wheelchair wearing a long sleeve shirt. Resident #31 was observed lying in bed under the blankets wearing gloves and a winter hat. Resident #44 was observed lying in bed with two blankets covered from his face to toes. All residents stated the rooms were always cold, that staff knew about it but did not do anything about it. Observations and temperature checks on 12/04/22 from 11:28 A.M. to 11:50 A.M. with the Maintenance Director revealed temperatures measured 68 to 70 degrees…

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 pureed sloppy joe was properly prepared and of the correct consistency. This had the potential to affect 13 residents (#4, #6, #10, #20, #22, #26, #29, #39, #41, #46, #52, #74, and #119) of 13 residents who received a pureed diet. The facility census was 65. Findings include: Observation on 12/06/22 at 11:31 A.M. revealed Dietary Staff (DS) #410 wash her hands and obtain the temperature of the cooked, Sloppy [NAME]. Observation of the robot coupe (food processor) revealed it was clean and dry. DS #410 poured the Sloppy [NAME] into the robot coupe, added hot water and six slices of bread then blended the mixture. At 11:35 A.M., DS #410 stopped the robot coupe and stated the it was done. DS #410 poured the finished Sloppy [NAME] into a small steam table pan. The Sloppy [NAME] appeared chunky, and a taste test revealed the Sloppy [NAME] was chunky with bites of meat. At this time Dietary Manager (DM) #451 tasted the sloppy joe 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 and interviews, the facility failed to ensure resident meal choices were obtained consistently. This affected 13 residents (#11, #14, #17, #18, #23, #32, #36, #42, #58, #59, #61, #63, and #76) and had the potential to affect all residents except Resident #35 who received nothing by mouth. Findings include: Observation of the lunch meal on 12/04/22 between 12:35 P.M. and 12:38 P.M. revealed Residents #14, #17, #23, #32, #36, #42, #59, and #76 were served chips, deli sandwich, and fruit cup. Interviews during this time with the residents revealed sometimes they received a menu and could choose between the main meal and an alternate. All stated they did not get that option on this date. They also complained there was a lack of food variety. Resident #17 stated he was not happy with what he received to eat for lunch. Interview on 12/04/22 at 3:32 P.M. with Dietary Staff (DS) #450 revealed residents usually received a menu for lunch and dinner with their breakfast trays so they could choose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure meals were served in a sanitary manner. This had the potential to affect all residents except Residents #4, #6, #10, #20, #22, #26, #29, #39, #41, #46, #52, #74, and #119 who received a pureed diet and Resident #35 who received nothing by mouth. The facility census was 65. Findings include: Observation of tray line on 12/06/22 at 12:12 P.M. revealed Dietary Staff (DS) #410 with gloved hands use a red and black plunger to pick up a metal hot pellet, place the pellet on an insulated bottom, then place a plate on top. DS #410 then opened the steamer with the same gloved hands, picked up a scoop to scoop a serving of pureed carrots that was in the steamer, and then finished making the pureed plate. Continued observation revealed DS #410 with the same gloved hands take a bun from a bag of buns and make a Sloppy [NAME] sandwich for a regular diet plate. DS #410 continued to prepare plates in the same manner without changing gloves or washing hands.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Long Term Care Ombudsman received copies of hospital transfer notices. This affected two residents (#13 and #66) of two residents reviewed for hospitalizations. The facility census was 65. Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/24/22. Diagnoses included chronic kidney disease, stage 4 (severe), acute kidney failure with tubular necrosis, hydronephrosis with ureteral stricture, major depressive disorder, and stroke. Review of the quarterly minimal data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required limited assistance of one staff for bed mobility, extensive assistance of staff for transfer and toilet use, and supervision with set-up help for eating. Review of the nurses note dated 09/21/22 at 7:58 P.M. revealed Resident #13's labs returned and the physician was notified of the results with critical values. Resident 13's physician gave a new…

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 care plans were developed for hospice and dialysis services. This affected Resident #45 who received hospice services and Resident #63 who received dialysis services. This affected one (Resident #45) of one resident reviewed for hospice and one (Resident #63) of one resident reviewed for dialysis. The facility census was 65. Findings include: 1. Review of the medical record for Resident #45 revealed an initial admission date of 08/26/22. Diagnoses included anxiety disorder, hypertension, hypothyroidism, unspecified, muscle weakness, and vascular dementia with behavioral disturbance. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required total dependence for one staff for bed mobility and eating, total dependence of two staff for transfers, and was receiving hospice services. Review of the nurses note dated 10/04/22 at 10:37 A.M. revealed Resident #45 had an increase…

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, interview and review of manufacturer instructions the facility failed to ensure Resident #32 was prompted or assisted to rinse mouth with water and expectorate to help reduce the risk of orophayrngeal yeast infection after administration of inhaled medication. This affected one (Resident #32) of five residents observed during medication administration. The census was 65. Findings include: Review of medical record for Resident #32 revealed an admission date of 08/25/20. Diagnoses included bipolar disorder, vascular dementia, chronic obstructive pulmonary disease, and malignant neoplasm of unspecified part of bronchus or lung. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/07/22, Resident #32 had intact cognition and required supervision for locomotion. Review of Resident #32's physician order dated 07/16/22 revealed an order to use a Breo Ellipta inhaler daily for chronic obstructive pulmonary disease. Observation on 12/04/22 at 9:13 A.M., Registered Nurse (RN) #461 administering Breo Ellipta inhaler to Resident #32. 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, record review, and interview, the facility failed to ensure oxygen tubing was changed in a timely manner. This affected one resident (#52) of one resident reviewed for respiratory care. The facility census was 65. Findings include: Review of the medical record for Resident #52 revealed an admission date of 10/29/22. Diagnoses included acute respiratory failure with hypoxia, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and asthma. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition, required limited assistance of one staff for bed mobility and toilet use, total dependence of two staff for transfers, and supervision with set-up help for eating, and used oxygen. Review of Resident #52's December 2022 physician orders revealed orders to change oxygen tubing every week on Sunday on 11:00 P.M. to 7:00 A.M. shift dated 10/30/22. Observation on 12/04/22 at 12:00 P.M. revealed Resident #52 in bed receiving…

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 pre and post dialysis assessments were completed for one resident (Resident #63). This affected one of one resident (Resident #63) reviewed for dialysis and one of eight resident reviewed for assessments. The facility census was 65. Findings include: Review of the medical record for Resident #63 revealed an admission date of 09/14/22. Diagnoses included end stage renal disease, moderate protein calorie malnutrition, hypertension, anemia and hepatitis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition, required limited assistance of one person for bed mobility, transfers, dressing and toilet use and supervision and set up help to eat. Review of the physician orders for November 2022 revealed Resident #63 received dialysis Monday, Wednesday and Friday. Review of the dialysis communication forms from 09/16/22 through 12/05/22 revealed no pre dialysis assessment was completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the attending physician documented the rational when pharmacy recommendations were not accepted and no medication changes were made. This affected two out of seven residents reviewed for unnecessary medications (Resident #5 and Resident #8). The facility census was 65. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/13/22. Diagnoses included schizophrenia, hypothyroidism, anxiety and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #5's physician's orders for December 2022 revealed an order for Ondanestron (Zofran) 4 milligrams (mg), a medication used to prevent nausea, to be given every eight hours as needed, and an order for Miralax 17 grams (gm), a medication to provide relief from constipation, was ordered every 24 hours as needed. Both orders had a start date on 05/13/22. Review of pharmacist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure medications were labeled with name of medication, expiration date, and cautionary instructions as applicable. This had the potential to affect 34 (Resident #2, #4, #5, #6, #7, #10, #11, #15, #16, #17, #18, #19, #20, #22, #25, #26, #27, #29, #30, #34, #35, #37, #41, #45, #46, #49, #51, #54, #55, #57, #58, #61, #63, and Resident #219) of 34 residents residing on the [NAME] unit. The census was 65. Findings include: Observations of medication administration on 11/04/22 at 8:59 A.M. revealed a medication cup filled with 12 medications inside the medication cart for the [NAME] unit. Interview at time of observation with Registered Nurse (RN) #458 revealed she could not identify the medications in the cup or who the medications were for. RN #458 stated the cup was in the top drawer from the night before. Interview on 12/05/22 at 3:22 P.M. with the Director of Nursing (DON) stated she looked up the medication based on the numbers printed on 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 Residents #39 and #48's comprehensive assessments were accurate. This finding affected two (Residents #39 and #48) of twenty-one resident records reviewed. The facility census was 54. Findings include: 1. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including supranuclear palsy, Parkinson's disease and chronic low back pain. Review of Resident #39's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment was on hospice services and was not coded for a life expectancy of less than six months. Review of Resident #39's physician order dated 10/15/19 indicated to admit the resident to hospice services with a diagnosis of supranuclear palsy, and the resident's prognosis was six months or less provided the disease followed its expected progression. Interview on 11/13/19 at 8:22 A.M. with Registered Nurse (RN) #801 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 interview and record review, the facility failed to monitor Resident #30's bowel movements and follow the facility bowel protocol ordered per her physician. This affected one resident (Resident #30) of one resident reviewed for constipation. The facility census was 54. Findings include: Review of medical record revealed Resident #30 had an admission date 08/18/16 with diagnoses of multiple sclerosis, constipation, quadriplegia, adult failure to thrive, reduced mobility, and supraventricular tachycardia. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #30 revealed she had impaired cognition and was totally dependent of two people with bed mobility and toileting. Transfers and locomotion did not occur. Review of care plan dated 08/18/16 for Resident #30 revealed she was at risk for impaired bowel elimination related to history of constipation. Interventions included; monitor bowel movements daily, monitor for bloating, lower abdominal pain, fecal impaction and report…

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

Based on observation, interview and record review, the facility failed to ensure Resident #21's oxygen was administered per the physician orders. This affected one (Resident #21) of four residents reviewed for respiratory care and had the potential to affect four additional residents (Residents #16, #37, #45, and #50) who required oxygen therapy. The facility census is 54. Findings include: Review of Resident #21's medical record revealed an admission date of 07/16/19 with diagnoses including chronic obstructive pulmonary disease (COPD), acute cholecystitis, protein calorie malnutrition, benign prostatic hyperplasia (BPH) and a pacemaker. Review of Resident #21's physician orders revealed an order dated 07/17/19 for oxygen to be administered at four liters per minute via nasal cannula. Review of Resident #21's respiratory care plan revealed an intervention dated 07/29/19 for staff to administer oxygen as ordered by the physician. Observation on 11/12/19 at 10:04 A.M. revealed Resident #21 sitting in a recliner in his room wearing a nasal cannula, and the dial on the oxygen…

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 State Tested Nursing Assistants (STNA) provided care within their scope of practice. This finding affected one (Resident #21) of four residents reviewed for oxygen therapy and had the potential to affect four additional residents (Residents #16, #37, #45, and #50) who required oxygen therapy. The facility census was 54. Findings include: Review of Resident #21's medical record revealed an admission date of 07/16/19 with diagnoses including chronic obstructive pulmonary disease (COPD), acute cholecystitis, protein calorie malnutrition, benign prostatic hyperplasia (BPH) and a pacemaker. Review of Resident #21's physician orders revealed an order dated 07/17/19 for oxygen to be administered at four liters via minute by nasal cannula. Review of Resident #21's respiratory care plan revealed an intervention dated 07/29/19 for staff to administer oxygen as ordered by the physician. Observation on 11/13/19 at 2:14 P.M. revealed Resident #21 was sitting in a specialized chair in his room wearing an oxygen nasal…

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.