Avenue Care And Rehabilitation Center, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure outdated drinks and food and beverage additives were stored in a manner to prevent spoilage. This had the potential to affect four ( #3, #28, #70, and #77) of four residents identified by the facility as receiving on thickened liquids. The facility census was 87.Findings include:Observation during a tour of the facility on 08/06/25 from 8:40 A.M. to 9:35 A.M. revealed two 46 ounce containers of nectar thickened orange juice were found in the [NAME] panties on the units. There was no date written on them to show when they had been opened. The use by date was June 2025. Further observation revealed eight individual thick and easy instant food and beverage thickener packets with a use by date of 10/29/23 found in the [NAME] pantries. On 08/06/25 at 9:41 A.M., Regional Director of Clinical Operations #808 verified the two containers of outdated nectar thickened orange juice and the eight outdated thick and easy instant food and beverage…

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, and policy review, the facility failed to ensure medical records were accurate and complete. This affected five (#1, #6, #30, #105, and #112) of 33 resident records reviewed. The facility census was 87.Findings include:1. Record review revealed Resident #1 was admitted [DATE] with diagnoses of sepsis, malignant neoplasm of left kidney, end stage renal disease, and dependance on renal dialysis. Review of the hospital admission referral packet dated [DATE] revealed Resident #1 was an end stage renal disease patient on a dialysis regimen with a Tuesday, Thursday, and Saturday schedule. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment, required hemodialysis, and required maximal assistance with toileting hygiene, showers, dressing, and personal hygiene. Review of the physician orders for [DATE] revealed Resident #1 had orders for atorvastatin calcium 10 milligrams (mg), donepezil five (5) mg,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure residents were provided with a dignified dining experience. This affected two (#25 and #95) out of three reviewed for respect and dignity. The facility census was 87. Findings include: 1. Review of Resident #95's medical record revealed an admission date of 06/18/24 and diagnoses included type two diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral, end stage renal disease (ESRD), and depression.Review of Resident #95's care plan revised 04/16/25 included Resident #95 had a self care deficit related to weakness, ESRD with hemodialysis, blindness to both eyes and limited mobility. Resident #95 would maintain the highest level of independence possible through the review date. Interventions included to provide eating set up and supervision.Observation on 08/05/25 at 8:44 A.M. of Certified Nurse Aide (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 observation, resident and staff interview, medical record review, review of an invoice, and review of the facility policy, the facility failed to ensure a resident's bed was appropriate to accommodate his height and weight and failed to ensure call lights were within reach for resident use. This affected three (#76, #44, and #95) out of seven residents reviewed for appropriate accommodation of needs. The facility census was 87.Findings include:1. Review of Resident #76's medical record revealed an admission date of 02/22/24 and diagnoses included paroxysmal atrial fibrillation, muscle weakness, difficulty walking, and pain. Review of Resident #76's height dated 02/22/24 revealed he was 81.0 inches (six (6) feet nine (9) inches) tall. Review of Resident #76's care plan dated 03/06/24 included Resident #76 had an alteration in musculoskeletal status related to muscle spasms, muscle weakness, and osteoarthritis. Resident #76 would remain free of complications related to fracture, such as contracture…

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, and review of a facility policy, the facility failed to ensure a resident's family or responsible party were notified of changes in condition. This affected one (#6) of two residents reviewed for change in condition. The census was 87.Findings include:Record review for Resident #6 revealed admission to the facility on [DATE]. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II and paroxysmal atrial fibrillation.Review of Resident #6's electronic medical record (EMR) revealed a nurse note dated 02/14/25 at 6:57 P.M. that Resident #6 was ordered to be sent to the hospital. There was no indication the family was notified. Further review revealed a note dated 02/19/25 at 4:10 P.M. that Resident #6 returned to the facility. There is no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 02/26/25 at 2:29 P.M. that Resident #6 was ordered to be sent to the hospital. There was no indication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure Notices of Medicare Non-Coverage (NOMNCs) were provided to Medicare Part A beneficiaries prior to the discontinuation of skilled services in a timely manner. This deficient practice affected two (#110 and #111) out of three residents reviewed for beneficiary notices. The facility census was 87. Findings included:1. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, metabolic disorder, and high blood pressure.Review of the NOMNC presented to and signed by Resident #110 on 05/08/25 revealed the notice indicated his skilled physical therapy, occupational therapy, and speech therapy services would end on 05/08/25. This provided no advance notice.2. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included a right femur fracture, type II diabetes, and high blood pressure.Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, review of self-reported incidents, review of discharge notices, and review of a policy review, the facility failed to ensure residents were permitted to return to the facility following a hospitalization and failed to ensure documentation of the need for discharge was reflected in the medical record to establish the need for discharge from the facility. This affected three residents (#18, #26 and #89) out of five residents reviewed for discharge. The facility census was 87.Findings include:1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses that included Parkinson’s disease, borderline intellectual functioning, and dementia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was severely cognitively impaired and required the assistance of one staff member for completing activities of daily living (ADLs). Review of the discharge notice issued on 07/31/25 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of an Ombudsman notification log, the facility failed to ensure the Ombudsman was notified of resident hospitalizations as required. This affected three (#6, #17, and #24) of five residents reviewed for discharges. The census was 87. Findings include: 1. Record review for Resident #6 revealed an admission to the facility on [DATE]. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II, and paroxysmal atrial fibrillation. Review of the electronic medical record (EMR) from 01/11/25 to present revealed Resident #6 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of the EMR revealed Resident #6 was admitted to the hospital on [DATE] and returned on 03/07/25. Resident #6 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the EMR revealed Resident #6 was sent to the hospital 06/10/25 and returned 06/12/25. Review of the Ombudsman Notification…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a significant change in condition Minimum Data Set (MDS) assessment was conducted for Resident #64 following a significant change as required. This affected one (#64) of one residents reviewed for hospice services. The census was 87.Findings included: Record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, seizures, and chronic obstructive pulmonary disease.Review of the hospice revocation form signed by Resident #64 on 04/24/24 revealed hospice services would be discontinued on 04/25/24 due to the resident's health improving and no longer meeting criteria to receive hospice services. Further review of Resident #64's medical record revealed the resident experienced a medical decline in 04/25/24 and was again receiving hospice services.Review of the MDS assessments for Resident #64 revealed no significant change assessment was completed following the resident'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 record review and staff interview, the facility failed to notify the appropriate state agency, the Ohio Department of Mental Health (ODMH), of a significant change in a resident's mental health condition, as required. This deficient practice affected one (#38) of two residents reviewed for pre-admission screening and resident review (PASRR). The facility census was 87.Findings included:Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included hemiplegia of the left side and aphasia.Review of the most recent psychiatric consult note dated 08/11/25 revealed Resident #38 had diagnoses of delusional disorder, dementia, and major depressive disorder. These diagnoses reflected onset dates of 06/29/23 and 07/02/23 respectively, as documented throughout the medical record.Review of PASRR records for Resident #38 revealed a PASRR was completed during the initial admission on [DATE]. No additional PASRR evaluations were completed during the resident's stay 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 staff interview, record review, and policy review, the facility failed to ensure an initial baseline care plan was initiated within 48 hours of admission as required. This affected one (#105) of four residents reviewed for baseline care plans. The facility census was 87.Findings include: Review of the medical record revealed Resident #105 was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, end stage renal disease dependent on hemodialysis, diabetes, a stroke, and vascular dementia without behavioral disturbance. The resident was admitted to hospice on [DATE] with a diagnosis of end stage renal disease after refusing to attend any further dialysis treatments. Resident #105 died on [DATE]. Review of Resident #105's comprehensive admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was moderately cognitively impaired and required dialysis treatments three times a week. Review of the admission assessment dated [DATE] for Resident #105…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure resident finger nail care was provided in an adequate manner. This affected one (#29) of six residents reviewed for activities of daily living (ADLs). The facility census was 87.Findings include:Review of Resident #29's medical record revealed an admission date of 12/21/21 and a re-entry date of 08/15/22. Resident #29's diagnoses included senile degeneration of the brain, anxiety disorder, and embolism and thrombosis of unspecified parts of the aorta. Review of Resident #29's care plan revised 03/25/25 included Resident #29 was resistive to care related to dementia and refused personal hygiene care and ADL management including showers. Resident #29 would cooperate with care through the next review date. Interventions included to give a clear explanation of all care activities prior to and as they occurred during each contact; if possible negotiate a time for ADLs so Resident #29…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to initiated orders timely and timely implement interventions for treatment of edema. This affected one (#88) of two residents reviewed for quality of care. The facility census was 87. Findings include:Record review revealed Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), acute upper respiratory infection, and shortness of breath (SOB).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact. She required partial to moderate assistance for toileting, upper body dressing, and personal hygiene. She required substantial to maximal assistance to shower, for lower body dressing, and donning and doffing footwear.Review of the current care plan for Resident #88 revealed a focus area of edema to bilateral lower extremities with interventions to apply ACE (compression)…

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 facility policy review, the facility failed to ensure Resident #31's unstageable pressure ulcer to the coccyx was accurately identified and treated timely. This affected one (Resident #31) of three residents reviewed for pressure ulcers. The facility census was 87.Findings include:Review of Resident #31's medical record revealed an admission date of 03/14/25 and diagnoses included heart failure, chronic kidney disease, and unspecified intellectual abilities.Review of Resident #31's admission Minimum Data Set assessment dated [DATE] revealed Resident #31 had severe cognitive impairment. Resident #31 required substantial to maximal assistance with toileting hygiene and bathing. Resident #31 required partial to moderate assistance for dressing and personal hygiene. Resident #31 had an indwelling catheter and was occasionally incontinent of bowel. Resident #31 did not reject care during the seven-day assessment look-back period.Review of Resident #31's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, review of fall investigations, review of an incident log, and review of facility policies, the facility failed to ensure thorough fall investigations were completed, resident care plans were revised to reflect current fall interventions, and fall interventions were in place as ordered. This affected three (#20, #24, and #25) of three residents reviewed for falls. The facility census was 87. Findings include:1. Review of Resident #25's medical record revealed an admission date of 07/03/23 with diagnoses that included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic respiratory failure, paranoid schizophrenia, bipolar disorder, anxiety disorder, and muscle weakness. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was assessed by staff as severely cognitively impaired. The resident had a functional limitation in range of motion (ROM) to both sides of the upper…

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 policy review, the facility failed to ensure residents were provided with timely incontinence care. This affected two (#5 and #77) of four residents reviewed for bowel and bladder incontinence. The census was 87. Findings include:1. Review of Resident #5's medical record revealed an admission date of 08/19/22 and diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type two diabetes mellitus without complications.Review of Resident #5's care plan revised 06/19/24 included Resident #5 had bowel and bladder incontinence related to decreased mobility, use of diuretic therapy, and cognitive impairment. Resident #5 would establish an individual bowel and bladder routine. Interventions included bowel protocol as ordered; briefs, depends or pantiliners when out of bed; check for incontinence every two hours and as needed; and toileting per request and as needed.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, staff interview, and policy review, the facility failed to ensure resident oxygen tanks were stored in a secured manner. This affected three (#57, #75, and #30) of 45 residents who resided on the first floor of the facility. The facility census was 87.Findings include: 1. On 08/06/25 at 1:25 P.M., observation with Maintenance Supervisor (MS) #748 revealed one free standing oxygen tank not properly chained or supported in a proper cylinder stand or cart in Resident #57's room [ROOM NUMBER]. On 08/07/25 at 12:34 P.M., observation made during the tour of the facility with MS #748 revealed one free standing oxygen tank not properly chained or supported in a proper cylinder stand or cart in Resident #75's room.3. On 08/07/25 at 12:54 P.M., observation made during the tour of the facility with the MS #748 revealed one free standing oxygen tank not properly chained or supported in a proper cylinder stand or cart in Resident #30's room.Interview with MS #748 verified the unsecured oxygen tanks in…

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

Based on medical record review and staff interview, the facility failed to ensure an antibiotic medication was administered as ordered. This affected one (#102) of two residents reviewed for urinary tract infections. The census was 87.Findings include: Review of the medical record for Resident #102 revealed an admission date of 05/01/25. Diagnoses included cellulitis of the left lower limb, pain in the left and right legs, anxiety disorder, and glaucoma. The resident discharged against medical advice (AMA) to an independent living facility on 07/22/25. Review of the Minimum Data Set (MDS) assessment, dated 05/08/25, revealed Resident #102 had intact cognition. The resident required supervision or touching assistance for dressing and mobility, used a walker and a wheelchair, and was occasionally incontinent.Review of Resident #102's physician orders for June 2025 revealed the resident was ordered a urinary analysis (UA) collection one time only for possible urinary tract infection (UTI) on 06/07/25 at 8:00 P.M.; the medication to treat UTI symptoms Pyridium oral tablet 100 milligrams…

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, and policy review, the facility failed to obtain laboratory values as ordered and failed to notify the physician of laboratory results as required. This affected one (#59) of two residents reviewed for urinary tract infections. The census was 87.Findings include:Review of Resident #59's medical record revealed an admission date of 10/20/17 and a re-entry date of 04/10/25. Resident #59's diagnoses included chronic obstructive pulmonary disease, asthma, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.Review of Resident #59's care plan dated 11/05/24 included Resident #59 had a suprapubic catheter related to obstructive uropathy diagnosis. Resident #59 would remain free from catheter related trauma through the review date. Interventions included to monitor, record, and report to the physician signs and symptoms of a urinary tract infection such as pain, burning, blood tinged urine, cloudiness etcetera; and monitor for signs…

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

Based on observation, medical record review, interview, and policy review, the facility failed to ensure personal protective equipment (PPE) was utilized when providing care for residents on enhanced barrier precautions and failed to handle contaminated items in a safe manner. This affected one (#95) of two residents observed for infection control precautions. The facility census was 87.Findings include: Review of Resident #95's medical record revealed an admission date of 06/18/24 and diagnoses included type two diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral, end stage renal disease, and depression.Review of Resident #95's care plan revised 04/15/25 included Resident #95 required enhanced barrier precautions to reduce transmission of multidrug resistant organisms (MDROs) related to hemodialysis. Resident #95's enhanced barrier precautions would be maintained through the review period. Interventions included to use disposable gowns and gloves during high contact care activities.Observation on 08/05/25 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 medical record review and staff interview, the facility did not ensure residents received COVID immunizations as requested. This affected three (#66, #86, and #55) of the eight residents reviewed for COVID immunizations. The census was 87. Findings include:1. Review of the COVID-19 vaccine informed consent form for Resident #66 revealed the form was reviewed verbally and was dated 10/28/24; however, the form did not specify if Resident #66 consented or refused the vaccine.Review of the medical record for Resident #66 revealed a COVID-19 vaccine had not been given since 05/23/23.2. Review of the COVID-19 vaccine informed consent form dated 02/20/24 for Resident #86 revealed verbal consent to receive the vaccine was provided by the power of attorney (POA). Review of the medical record revealed Resident #86 never received a COVID-19 vaccine.3. Review of the COVID-19 vaccine informed consent form dated 10/28/24 for Resident #55 revealed verbal consent to receive the vaccine was provided by the resident. Review of the medical record for Resident #55 revealed a COVID-19 vaccine…

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, staff interview, and review of manufacturer's instructions, the facility failed to ensure side rails were securely attached and in place to prevent resident entrapment or other accidents. This deficient practice affected three (#50, #55, and #79) of 22 residents who utilized side rails for safety. The census was 87.Findings included:Observation during an environmental tour conducted on 08/06/25 between 1:00 P.M. and 1:55 P.M. with Maintenance Supervisor (MS) #748 revealed the side rails on the beds of Resident #50, Resident #55, and Resident #79 were not secure, were extremely loose, and were not tightly affixed to the sides of the beds.Interview with MS #748 at the time of discovery confirmed the side rails were loose and not securely attached to Resident #50, Resident #55, and Resident #79's beds.Review of the undated manufacturer's instructions for the bed rails utilized by Resident #50, Resident #55, and Resident #79 revealed after any adjustments, repair or service and before use, make sure all attaching hardware is tightened securely.

Based on closed record review, facility policy review and interview, the facility failed to report an incident of neglect involving Resident #95 to the State Agency as required. This affected one resident (#95) of four residents reviewed for neglect. The facility census was 91. Findings include: Review of Resident #95's closed medical record revealed an admission date of 12/18/24 with diagnoses including adult failure to thrive, malnutrition and metabolic encephalopathy. Review of a social service progress note, dated 12/19/24, revealed Resident #95 admitted to the facility for short term rehabilitation services after a recent hospitalization. She was a full code status (advance directives) and her discharge plan was to return to her private residence where she lived alone. The note indicated Resident #95 received support from her brother. Resident #95 used a cane and a walker at home. The note indicated Resident #95 was a questionable historian who seemed confused. Review of Resident #95's care plan, initiated on 12/23/24 revealed the resident was identified to be a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident bathing preferences were honored. This affected four (Residents #21, #29, #34, and #58) of six residents reviewed for accommodation of needs. The facility also failed to ensure residents preferences regarding transfer in and out of bed were honored. This affected two (Residents #21 and #65) of six residents reviewed for accommodation of needs. The facility census was 91 residents. Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of [DATE] with diagnoses including exocrine pancreatic insufficiency, muscle weakness, and difficulty in walking. Review of the care plan for Resident #21 dated [DATE] the resident had an activities of daily living (ADL) self-care performance deficit. Interventions included the following: provide assistance by staff with bathing/showering two times a week and as necessary, provide assistance by staff 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.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to offer/provide timely incontinence care. This affected two (Residents #16 and #65) of three residents reviewed for incontinence care. The facility census was 91 residents. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 11/19/15 with a readmission date of 05/14/21 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and Alzheimer disease with late onset. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 04/23/24 revealed the resident was cognitively impaired, had impairment to one side upper and lower extremity, used a wheelchair, required substantial/maximum assistance with toileting and personal hygiene, was dependent with transfers, and was always incontinent of bowel and bladder. Review of the care plan for Resident #16 dated 04/25/23 revealed the resident had bowel and bladder incontinence related to dementia 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, interview, record review and facility policy review, the facility failed to administer medications to Resident #52 without verifying that he ingested all the medications. This affected one resident (#52) of five residents reviewed for accidents. The facility census was 87. Findings include: Review of the medical record for Resident #52 revealed an admission date of 05/02/22. Diagnoses included cerebral infarction, asthma, hemiplegia, and hemiparesis following cerebral infarction, and chronic obstructive pulmonary disease. Review of the physician's order dated 05/03/22 revealed an order to administer vitamin B12 (supplement)1000 micrograms (mcg) daily in the morning to Resident #52. There also was an order dated the same date that Resident #52 may not self-administer his medications. Review of physician's order dated 11/29/22 revealed an order to administer metoprolol succinate (antihypertensive) 25 milligrams (mg) in the morning, and multivitamin daily to Resident #52. Review of physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, the facility failed to ensure an open bottle of a controlled drug level two substance brought from home was handled properly to ensure accurate administration, failed to ensure accurate orders for a controlled drug level two substance were documented in Resident #84's medical record and failed to ensure verification of orders of a controlled drug level two substance with Resident #84's physician upon admission to the facility. This affected one resident (Resident #84) out of five reviewed for appropriate procedures followed for controlled drug level two substances. The facility census was 79. Findings include: Review of Resident #84's medical record revealed an admission date of [DATE] and diagnoses included malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary neoplasm of the brain and chronic obstructive pulmonary disease. Resident #84 expired at the facility on [DATE]. Review of Resident #84's Nursing…

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, hospital record review, review of the facility assessment, review of facility policy and interviews with facility and hospital staff, the facility failed to ensure Resident #82 was allowed to return to the facility following a hospitalization for a psychiatric evaluation. This affected one resident (#82) of three residents reviewed for transfer/discharge. The facility census was 82. Findings include: Review of the medical record for Resident #82 revealed an admission date of 06/09/23 and diagnoses including schizophrenia, chronic obstructive pulmonary disease, type two diabetes, and cirrhosis of the liver. Resident #82 was his own responsible party and was discharged to the hospital on [DATE] for a psychological evaluation after displaying aggressive behaviors towards staff on 08/22/23. Resident #82's payer source was Medicaid. Review of Resident #82's admission Minimum Data Set (MDS) 3.0 assessment, dated 06/22/23, revealed Resident #82 had intact cognition. The 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.

Based on observation, interview, and review of Resident Council minutes, the facility did not ensure foods were discarded prior to spoilage, foods were free from ice buildup in the freezer, and scoops were stored outside of bulk food bins. This had the potential to affect all 77 residents who received food from the kitchen. The facility identified two residents (#28 and #71) that received nothing by mouth. The facility census was 79. Findings include: Observation on 05/21/23 from 8:14 A.M. to 8:45 A.M., initial tour of the kitchen revealed a large white bin labeled puree thickener with two Styrofoam cups inside, six containers of molded strawberries in the walk-in refrigerator, ice buildup on two boxes of sliced pepperoni in the walk-in freezer, and 12 bowls of cut fruit (dated 05/17/23) on the tray line for breakfast service that contained molded fruit. On 05/21/23 at 8:32 A.M., interview with Dietary Aide #552 verified there were two Styrofoam cups inside the bin of puree thickener and there were six containers of molded strawberries in the walk-in refrigerator. On 05/21/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure resident Minimum Data Set (MDS) 3.0 assessments were completed accurately. This affected three residents (#26, #29, and #33) of 25 residents whose MDS assessments were reviewed. The facility census was 79. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 10/18/11. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus, unspecified dementia, dysphagia, and aphasia. Review of the care plan dated 11/01/21 revealed Resident #26 had an activity of daily living (ADL) deficit related to hemiplegia, impaired balance, and limited mobility. Intervention included bilateral half side rails to bed for mobility and positioning. Review of the physician orders for Resident #26 revealed an order dated 12/06/22 for bilateral half side rails to bed for mobility and positioning. Review of the quarterly Minimum Data…

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 develop a person-centered baseline care plan for Resident #277. This affected one resident (#277) of three residents reviewed for baseline care plans. The facility census was 79. Findings include: Review of the medical record for Resident #277 revealed an admission date of 05/05/23. Diagnoses included congestive heart failure, hypertension, muscle weakness, and repeated falls. Review of the Nursing - admission Care Plan - V 3 dated 05/08/23 revealed Resident #277 required transfer assist of one person. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #277 required extensive assistance of two people for transfers. Review of the care plan initiated 05/05/23 and revised 05/23/23 revealed Resident #277 had a plan of care for a Hoyer (mechanical) lift transfer with assist of two people (added 05/23/23) and a plan of care for a one person assist with transfers (added 05/05/23). On 05/23/23 at 8:12 A.M., interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to develop a person-centered care plan for Residents #5 and #56. This affected two residents (#5 and #56) of two residents who were reviewed with bilateral amputations. The facility census was 79. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 12/29/22. Diagnoses included acquired absence of right leg below the knee, acquired absence of left leg above the knee, peripheral vascular disease, and acute and chronic congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, required extensive assist of two or more personnel for bed mobility, toilet use, personal hygiene, and required total dependence of two or more personnel for transfers. Review of the progress notes for Resident #5 revealed a nursing note from 01/03/23 at 5:27 P.M. that revealed that resident was able to move all extremities…

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, observations, interview, and facility policy review the facility failed to ensure all residents were provided adequate and timely assistance with activity of daily care to meet their total care needs. This affected three residents (#25, #61, and #277) of five residents reviewed for activities of daily living. The facility census was 79. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 03/07/23. Diagnoses included cerebral infarction, schizoaffective disorder, hemiplegia/hemiparesis affecting right dominant side, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. The resident required extensive assistance for personal hygiene and bed mobility. Review of the shower sheets for April and May 2023 revealed Resident #25 received 14 showers during the two months. Staff had documented on the shower sheets six times indicating the resident needed toenails trimmed.…

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 pressure ulcer treatments were completed as ordered for Resident #329 and failed to maintain adeqauate infection control practices during wound care to prevent the spread of infection to the resident. This affected one resident (#329) of five residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #329 was admitted to the facility on [DATE] with diagnoses including closed fracture of left femur with routine healing, diabetes mellitus type two, heart failure, peripheral vascular disease, chronic kidney disease stage three, paroxysmal atrial fibrillation, and essential primary hypertension. Review of the plan of care dated 04/25/23 revealed Resident #329 had pressure ulcers related to a left hip surgical incision line and immobility. Interventions included barrier cream as ordered; to encourage and assist to reposition with care rounds and as needed; to float heels while in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of the facility policy, the facility failed to provide adequate assistance to Resident #277 during a Hoyer (mechanical) lift transfer. This affected one resident (#277) of three residents reviewed for falls/accidents. The facility census was 79. Findings include: Review of the medical record for Resident #277 revealed an admission date of 05/05/23. Diagnoses included congestive heart failure, hypertension, muscle weakness, and repeated falls. Review of the Nursing - admission Care Plan - V 3 dated 05/08/23 revealed Resident #277 required transfer assist of one person. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #277 required extensive assistance of two people for transfers. On 05/23/23 at 7:12 A.M., observation of Resident #277 revealed State Tested Nurse Aide (STNA) #502 transferring Resident #277 using a Hoyer lift device. No other staff were present in the room at the start of the transfer. STNA #502…

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 accurately document completed treatments provided for Residents #5 and #56. This affected two residents (#5 and #56) of two residents whose medical records were reviewed related to treatments. The facility census was 79. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 12/29/22. Diagnoses included acquired absence of right leg below the knee, acquired absence of left leg above the knee, peripheral vascular disease, and acute and chronic congestive heart failure. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, required extensive assist of two or more personnel for bed mobility, toilet use, personal hygiene, and required total dependence of two or more personnel for transfers. Review of the care plan dated 12/30/22 revealed Resident #5 had a left above the knee and a right below the knee amputation. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff provided the hand splint for Resident #45 per his restorative program. This affected one out of one resident reviewed for restorative services. Findings include: Resident #45 was admitted on [DATE] with diagnoses including cerebral vascular accident (stroke) with right sided hemiplegia (paralysis on one side of the body), schizophrenia, dementia, heart disease and kidney disease. A plan of care initiated on 02/02/18 indicated Resident #45 had an activity of daily living self-care deficit related to his disease process. The interventions included to provide a physical and occupational therapy evaluation and treatment per physician orders. Resident #45's Minimum Data Set (MDS) assessment dated [DATE] indicated he was alert and oriented with intact cognition. A review of Resident #45's Restorative Rehabilitation Program Recommendation form dated 07/03/19 indicated staff were to apply Resident #45's hand splint to his right hand at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medical record accurately reflected medication administration for Resident #36, supplement intake for Resident #64, and use of an orthotic device for Resident #72. This affected three of 23 resident records reviewed. Findings include: 1. Review of the record revealed Resident #64 was admitted on [DATE] with diagnoses including diabetes and hypertension. Review of weights indicated Resident #64 weighed 283 pounds on 02/21/19 and 249.4 pounds on 05/17/19. A dietary progress note dated 05/20/19 indicated the resident was readmitted from the hospital on [DATE]. She had a significant weight loss over 30 day. The dietician added Boost Glucose Control 237 milliliters (ml) once daily and ordered weekly weights. Resident #64 had a physician order dated 05/24/19 for glucose control supplement two times a day, and staff were to record the percent (%) consumed. On 05/30/19, the supplement was increased to four times daily. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain respiratory equipment for Resident #33 and Resident #28 and failed to complete a dressing change for Resident #72 in a sanitary manner to prevent contamination. This affected two of two residents reviewed for respiratory equipment and one of two residents reviewed for dressing changes. Findings include: 1. Record review of Resident #33 revealed an admission date of 02/26/17 with diagnoses including acute respiratory failure with hypoxia (low oxygen levels), Alzheimer's disease, and schizophrenia. Review of the minimum data set (MDS) assessment dated [DATE] indicated Resident #33 required extensive assistance for bed mobility and transfers. Observation of Resident #33's room on 08/19/19 at 9:30 A.M. revealed the breathing treatment/nebulizer mask was laying on the top dresser. The nebulizer mask was observed without any protective covering to prevent contamination. Interview and observation with License Practical Nurse (LPN) #9 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.