Ayden Healthcare Of Wauseon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a hemodialysis communication binder, staff interview, and review of the facility policy, the facility failed to ensure hemodialysis access sites were monitored as care planned, and failed to ensure communication between the hemodialysis clinic and the facility regarding a resident's hemodialysis and services was maintained. This affected one (#200) of one resident reviewed for hemodialysis. The facility census was 45. Findings include: Review of the medical record for Resident #200 revealed an admission date of 08/09/24 with diagnoses of type II diabetes mellitus and end stage renal disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition, received hemodialysis, and was on a therapeutic diet. Review of the current care plan for Resident #200 revealed he received hemodialysis. Interventions included monitoring the hemodialysis site for signs or symptoms of infection or bleeding. Review of the physician…

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, and medical record review, the facility failed to ensure resident's food preferences were followed. This affected two (#20 and #26) of seven residents reviewed for food preferences. The facility census was 45. Findings Included: 1. Review of Resident #26's medical record revealed an admission date of 07/27/23. Diagnosis included diabetes mellitus, absence of right toes, and iron deficiency anemia. Review of Resident #26's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident had no natural teeth and required set up or clean up assistance for eating. Review of Resident #26' most recent care plan revealed she suffered from anemia and diabetes mellitus type two. The resident was at risk for hyper/hypoglycemia episodes related to diabetes mellitus type two. Review of Resident #26's physician order revealed an order dated 01/18/24 for a regular diet, regular texture, and thin consistency. No chips or sharp…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, interview, and policy review, the facility failed to ensure a resident with an indwelling urinary catheter was placed on enhanced barrier precautions. This affected one (#5) of one resident reviewed for urinary catheters. The facility census was 45. Findings include: Review of the medical record for Resident #5 revealed an admission date of 09/20/22. Diagnoses included multiple sclerosis, urinary retention, neuromuscular dysfunction of the bladder, malignant neoplasm of right kidney, osteoarthritis, and venous insufficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of a progress note dated 06/10/24 at 10:58 A.M. revealed Resident #5 would be returning from the hospital with an indwelling urinary catheter. Observation on 08/19/24 at 9:06 A.M. revealed Resident #5 had an indwelling urinary catheter. Further observation revealed the resident was not on enhanced barrier precautions…

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, resident interview, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all residents who receive food from the facility's kitchen. The facility census was 47. Findings include: Observation on 08/01/24 at 7:40 A.M. of meal delivery to the south hall revealed the door to the meal delivery cart was left open between delivery of each tray. Observation on 08/01/24 at 7:42 A.M. of meal delivery to the south hall revealed 11 plate covers (from previously delivered trays), one undelivered resident tray, and a tote of condiments on top of the meal delivery cart. Interview on 08/01/24 at 7:47 A.M. with State Tested Nursing Assistant (STNA) #219 revealed the top of the meal delivery cart for the south hall had 11 plate covers (from previously delivered trays), one undelivered resident tray, a tote of condiments on top, and the door was let open in-between delivering trays. Concurrent interview on 08/01/24 at 7:47 A.M. with STNA #219 revealed they receive multiple complaints daily from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure residents had a safe, clean, comfortable environment. This affected one resident (#35) and had the potential to affect an additional 36 residents (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, #15, #17, #19, #20, #21, #22, #23, #25, #26, #27, #29, #31, #32, #33, #34, #38, #39, #40, #42, #43, #44, #45, #46, ) residing in the facility. The facility census was 47. Findings include: Review on 07/24/24 at approximately 2:00 P.M. revealed Resident #35 was admitted on [DATE] with diagnoses of severe protein-calorie malnutrition, non-ST elevation myocardial infarction (NSTEMI), acidosis, peripheral vascular disease (PVD), unsteadiness on feet, adult failure to thrive, anorexia, right foot drop, hypertension (HTN), drug induced constipation, cognitive communication deficit, muscle wasting and atrophy, muscle weakness, dysphagia, difficulty in walking, hypomagnesia, and depression. 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.

Based on observations, staff interviews, and policy review, the facility failed to ensure residents were safely smoking. This affected one (Resident #48) of one resident observed for smoking. The facility census was 47. Findings include: Observation on 08/01/24 at 7:35 A.M. revealed Resident #48 outside of the facility at the end of the north hall smoking a cigarette unattended in a non-designated smoking area with no flame-retardant receptacle to extinguish smoking materials into. Concurrent observation on 08/01/24 at 7:35 A.M. of Resident #48 revealed Resident #48 extinguish their cigarette with their hand and place unused portion in their pocket. Observation on 08/01/24 at 7:53 A.M. of Resident #48 revealed a package of cigarettes in their left sock. Interview on 08/01/24 at 8:33 A.M. with the Director of Nursing (DON) revealed the facility is implementing a new smoking policy on 08/01/24, but the residents and staff have not been educated on it. Concurrent interview on 08/01/24 at 8:33 A.M. with the DON revealed Resident #48 has a locked drawer in his room to store his…

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

Based on review of staff schedules, staff on duty hours daily postings, staff timecards and staff interviews, the facility failed to ensure a Registered Nurse (RN) was on duty for eight hours a day seven days a week. This has the potential to affect 39 of 39 residents in the facility. The census is 39. Findings include: Review on 02/15/22 at 9:00 A.M., of the staff schedules for 02/12/22 revealed no RN was scheduled to work. Registered Nurse (RN) #56 was scheduled from 2:30 A.M. until 6:30 A.M. on 02/13/22. Further review of staff schedules for Sunday, 02/13/22 revealed one (RN) #39 scheduled from 6:30 A.M. until 12:30 P.M. Review of staff on duty hour postings on 02/15/22 at 9:05 A.M., revealed zero registered nurse hours on Saturday, 02/12/22 and six register nurse hours on Sunday, 02/13/22. Review of timecard on 02/16/22 at 8:48 A.M., for RN #56 revealed a clocked in at 2:58 A.M. on 02/13/22 and clocked out at 7:09 A.M. on 02/13/22 for a total of 4.08 hours. Review of timecard on 02/16/22 at 8:50 A.M., for RN #39 revealed a clocked in on 02/13/22 at 6:29 A.M. and clocked out 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 observations, staff interviews, infection control log reviews and review of policies, the facility failed to store, prepare, and distribute foods in a safe, sanitary manner. This affected 38 of 38 residents who received food from the kitchen. The facility identified one (#36) resident had an order for nothing by mouth. The facility census was 39. Findings include: Observation on 02/14/22 at 9:26 A.M., revealed the reach-in refrigerator contained a container of chili dated 01/27/22, and a container of chili with meat dated 01/30/22, and an undated Styrofoam container of cupcakes. Interview at the time of the observation, with the [NAME] #60, confirmed the chili was beyond its use-by date and the cupcakes were undated. Observation on 02/14/22 at 9:31 A.M., revealed a box of sprouting and rotted red skinned potatoes in the dry storage area. Interview at the time of the observation, with the [NAME] #29, confirmed the potatoes were sprouting and rotted. Observation on 02/14/22 at approximately 9:34 A.M. revealed four and a half gallons of chocolate milk labeled best if used by…

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

Based on review of the facility Legionella Control Risk Management Plan, staff interview and review of facility policy, the facility failed to monitor and implement control measures to prevent Legionella growth. This had the potential to affect 39 of 39 residents in the facility. The facility census was 39. Findings include: Review of the facility risk management plan for Legionella Control, updated 11/2021, revealed thee facility identified pipe work with low flow in several areas and would flush the areas weekly. Also, the facility would monitor the hot water system, measure the temperature weekly and make adjustments if the temperature was below 140 degrees Fahrenheit. Additionally sink basin and shower heads would be cleaned monthly of scale and lime build up to ensure proper water flow. Furthermore the facility would test the water system for colony forming units (CFUs) of Legionella per milliliter of water. Interview on 02/16/22 at 2:51 P.M., with the Administrator verified the facility had not been flushing water in low flow areas, and had not monitored water temperatures 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 resident record review, resident interview, resident family interview, staff interview, and policy review; the facility failed to provide the resident/resident representative a written summary of the baseline care plan. This affected two (#338 and #36) of four residents reviewed for baseline care planning. The census was 39. Findings include: 1. Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE]. Diagnoses include respiratory failure, diabetes mellitus type two, and hypertension. Review of the medical record for Resident #338 revealed a baseline care plan dated 01/26/22. The medical record contained no evidence of Resident #338 or of the resident's representative being provided a written summary of the baseline care plan. Review of an admission minimum data set (MDS) assessment target date 02/02/22, revealed Resident #338 had intact cognition. Interview on 02/14/22 at 9:53 A.M., with Resident #338 revealed the resident was not given a copy 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 review of medical records, staff interview, family interviews, resident interviews and review of policy, the facility failed to revise care plans and failed to ensure residents/resident representatives were given the opportunity to participate in the care planning process. This affected five (#7, #32, #338, #36, #9) of 12 residents reviewed for care planning. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #7 had an admission date of 06/29/20. Diagnosis included multiple sclerosis, chronic pain syndrome and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan conference notes revealed the resident's last care conference meeting was completed 04/13/21. Interview on 02/17/22 at 9:11 A.M., Resident #7 revealed she had not been to a care plan meeting in a long time. Resident #7 revealed it was important to have the meeting to find out what is going…

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 interviews, review of dietary spreadsheets, and review of facility policies, the facility failed to prepare and serve pureed foods in a manner to maintain nutritional value. This affected five (#3, #4, #20, #28, and #287) of five residents on a pureed diet. The facility census was 39. Findings include: Observation on 02/15/22 at 11:04 A.M., revealed the [NAME] #60 placed five Salisbury steaks in a food processor and used an unknown amount of water to make pureed meat. Interview at that time of the observation, with the [NAME] #60, revealed there were six residents on a pureed diet, and he confirmed he used five Salisbury steaks, not one for each resident. Observation on 02/15/22 at approximately 11:35 A.M., revealed one resident on a pureed diet received double protein portions, and the [NAME] #60 provided two scoops of a two-ounce scoop of pureed Salisbury steak on the tray. Two additional residents were served one two-ounce scoop of pureed meat. Interview on 02/15/22 at 11:40 A.M., with the [NAME] #60 revealed he used a two-ounce scoop for the pureed…

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 reviews, observations, staff interviews and policy review, the facility failed to provide care in a manner to promote dignity. This affected two (#337 and #11) of 39 sampled residents. The facility census was 39. Findings include: 1. Review of the medical record for Resident #337 revealed an admission date of 02/10/22. Diagnoses for Resident #337 included spina bifida, pressure ulcer of right hip stage four, morbid (severe) obesity due to excess calories, hypertensive retinopathy, bilateral, type 2 diabetes mellitus with diabetic polyneuropathy, other chronic osteomyelitis, history of COVID-19, acquired absence of left leg below knee, and unspecified convulsions. Further review of the medical record revealed the Minimum Data Set (MDS) and the Comprehensive Care Plan had not been completed. Observation on 02/14/22 at 11:10 A.M., revealed Resident #337's catheter bag was uncovered with visible urine in the bag, the door was closed and not in view from the hallway. Observation on 02/15/22 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 observations, medical record resident and staff interviews, and policy review, the facility failed to ensure a resident was provided assistance with shaving. This affected one (#5) of three residents reviewed for assistance with activities of daily living (ADL). The census was 39. Findings include: Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses include arthropathy, disturbances of skin sensation, muscle weakness, hypertension. osteoarthritis, and lesion of the median nerve. Review of a care plan dated 02/21/20 revealed Resident #5 had an ADL self care deficit as evidenced by need for assistance related to inability to stand for any length of time secondary to bilateral leg weakness, decreased endurance, decreased activity tolerance, and limited range of motion in hands related to arthritis. Interventions include assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Review of a quarterly minimum data set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and policy review, the facility failed to ensure a resident received hydration per physician orders for tube feeding flushes. This affected one (#36) of one resident reviewed for hydration. The facility census was 39. Findings include: Review of the medical record for Resident #36 revealed an admission date of 01/20/22 and medical diagnoses of cerebral infarction, type 2 Diabetes Mellitus, dysphagia, persistent vegetative state, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was in a persistent vegetative state, required extensive assistance of two staff for bed mobility, toileting, and personal hygiene, and was totally dependent for eating. Review of the physician orders for Resident #36 revealed an order dated 02/11/22 for enteral feed every shift for nutrition 80 milliliters (mL) per hour continuous infusion, flush with 40 mL per hour. Further review revealed a diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the dialysis agreement, the facility failed to ensure communication to correlate care was provided by the dialysis clinic for residents receiving hemodialysis. This affected one (#9) of one resident reviewed for hemodialysis. The facility identified two residents on hemodialysis. The facility census was 39. Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/29/20 and medical diagnoses of end stage renal disease, type 2 Diabetes Mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. Resident #9 required supervision with setup help only for transfers, walking, eating, toileting and hygiene. Review of the progress notes revealed no documentation the facility received updates from the dialysis clinic. Review of the hemodialysis communication book for Resident #9 revealed no communication sheets from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview, the facility failed ensure medication was timely administer as ordered by the physician. This affected one (#338) of six residents reviewed for unnecessary medication. The census was 39. Findings include: Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE]. Diagnoses include respiratory failure, Diabetes Mellitus type two, and hypertension. Review of the hospital discharge instructions dated 01/26/22, revealed the Resident #338 was admitted to the facility with orders to receive the following medication on 01/26/22: famotidine 20 milligram (mg) tablet at 9:00 P.M. and insulin glargine 35 units subcutaneous as directed. Review of the medical record for Resident #338 revealed the resident was admitted to the facility on [DATE] at approximately 4:20 P.M. Review of the medication administration record (MAR) dated January 2022, revealed an order for famotidine table 20 mg give one tablet by mouth every morning…

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 as needed (PRN) psychotropic medications had a stop date after 14 days of use. This affected one (#13) of five sampled residents reviewed for unnecessary medications. The facility identified 18 residents that receive psychotropic medications. The facility census was 39. Findings include: Review of the medical record revealed an admission date of 12/09/20. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, emphysema, essential hypertension, anxiety disorder, major depressive disorder, recurrent, urinary incontinence, and gastro-esophageal reflux disease without esophagitis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderate cognitive impairment. No behaviors were exhibited during the assessment period. Resident received antipsychotic, antianxiety, and opioids seven days during the assessment period and diuretics three days during the…

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

Based on medical record review and staff interview, the facility failed to timely respond to a pharmacist recommendation for three residents (#5, #17 and #21). Furthermore, the facility failed to ensure the policy included the specific time frames for the steps of the Medication Regimen Review process. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the medical record of Resident #5 revealed an admission date of 11/01/06. Diagnoses included dementia with behavioral disturbance and type two diabetes mellitus. Review of the progress notes revealed a Medication Regimen Review Note dated 09/05/18. The note indicated an order indicated fasting blood sugar and hemoglobin A1C (a lab test that tells you the average level of blood sugar over the past two to three months) every six months in February and July. At the time of the review, a Hemoglobin A1C and fasting blood sugar could not be located in the clinical record. Please consider the recommendation to follow up with the lab and monitoring fasting blood sugar and Hemoglobin A1C…

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, facility record review and review of facility policies, the facility failed to ensure appropriate kitchen sanitation and proper food storage. This had the potential to affect all 40 residents in the facility. The facility stated all residents ate food from the kitchen. Findings include: 1. Observation of the facility refrigerator with Dietary Manager (DM) #200 on 06/03/19 at 9:40 A.M. revealed unlabeled chopped turkey pieces in a clear zip top bag, one unlabeled plastic container of sweet potatoes, one unlabeled plastic container of coleslaw, one unlabeled plastic container of peach crisp, one unlabeled clear bag of cheese slices, and one opened zip bag of sliced turkey labeled 05/20/19. Dietary Manager #200 at time of the above observations verified these findings. She stated opened containers of food should be labeled and used within five days. Review of a facility policy titled Food Storage, dated 03/2017, revealed leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before…

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 a facility dietary spreadsheet, the facility failed to ensure the dietary spreadsheet was followed as approved by the dietitian. This affected 13 residents (#1, #5, #7, #12, #21, #22, #24, #33, #37, #39, #42, #43 and #197) who received a regular meat entree and five residents (#1, #21, #23, #24, and #43) who received a puree diet. The facility census was 40. Findings include: 1. Observation of lunch service on 06/04/19 at 11:15 A.M. with Dietary Manager #200 revealed residents were served a very small chicken breast. Review of the facility spreadsheet revealed residents were to receive a four ounce chicken breast. Interview with Dietary Manager #200 at time of service revealed the chicken breast served was three ounces. She verified the dietary spreadsheet indicated a four ounce chicken breast for those who received the regular entrée. She stated she did not have a policy regarding following the dietary spreadsheet. Review of the facility's list of residents on a regular diet revealed Resident #1, #5, #7, #12, #21, #22, #24, #33,…

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, review of the infection control log, staff interview and policy review, the facility failed to re-educate staff members when a trend of urinary tract infections was noted in 04/2019. This affected five residents (#14, #29, #35, #42 and #43). The facility census was 40. Findings include: Review of the medical record of Resident #14 revealed an admission date of 09/08/18. Review of the facility log for infections for 04/2019 revealed Resident #14 had an onset date of 04/01/19 and 04/30/19 with a urinary tract infection (UTI.) The form revealed the organisms to be Proteus Mirabilis and Escherichia coli. Review of the medical record of Resident #29 revealed an admission date of 03/11/19. Review of the facility log for infections for 04/2019 revealed Resident #29 had an onset date of 04/03/19 with a urinary tract infection (UTI.) The form revealed the organism to be Escherichia coli. Review of the medical record of Resident #35 revealed an admission date of 03/29/19. Review of the facility log for infections for 04/2019 revealed Resident #35 had an onset…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and facility policy review, the facility failed to notify the physician of new pressure wounds for a resident. This affected one (Resident #35) of one resident reviewed for physician notification. The facility census was 40. Findings include: Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included chronic kidney disease, diabetes, hypertension, anemia and urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/19, revealed she was cognitively impaired and was not interviewable. Review of the medical record revealed Resident #35 had pressure wounds at her right heel, left heel and left ischium. There was no documentation of any wounds on Resident #35's coccyx. Review of the physician order dated 05/01/19 revealed to apply barrier cream to coccyx twice daily and as needed. Interview on 06/04/19 at 1:13 P.M. with Licensed Practical…

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 facility policy review, the facility failed to issue a bed hold notice to a resident. This affected one (Resident #44) of one resident reviewed for hospitalization. The facility census was 40. Findings include: Review of the medical record of Resident #44 revealed an admission date of 01/14/19 and a discharge date of 04/05/19. Diagnoses included obstructive and reflux uropathy, dementia, hypertension, atrial fibrillation and presence of automatic cardiac defibrillator. Review of the progress notes, dated 04/05/19 at 4:18 A.M., revealed Resident #44 had a change in condition with heart rate of 136 beats per minute, respirations of 43 breaths per minute, a temperature of 102.6 degrees Fahrenheit and a low peripheral capillary oxygen saturation. Resident #44 was not responding as was normal for him. The doctor was notified and an order was received to send Resident #44 to the emergency room for an evaluation. Resident #44's wife was notified and apprised 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, observation, staff interview and facility policy review, the facility failed to provide care and treatment of new pressure wounds for a resident. This affected one (Resident #35) of three residents reviewed for pressure wounds. The facility identified four residents with pressure ulcer wounds. The facility census was 40. Findings include: Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included chronic kidney disease, diabetes, hypertension, anemia and urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment, dated 04/05/19, revealed she was cognitively impaired and was not interviewable. The resident required extensive assistance of two staff with her activities of daily living. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 03/30/19, revealed she was at moderate risk of developing pressure wounds. Review of the medical record revealed Resident #35 had…

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 and resident interview, and review of a facility policy, the facility failed to ensure a resident's respiratory equipment was properly maintained. This affected one (Resident #40) of two residents reviewed for respiratory care. The facility identified 17 residents receiving oxygen and/or nebulizer therapy. The facility census was 40. Findings include: Review of Resident #40's medical record revealed an admission date of 10/01/17. Medical diagnoses included myocardial infarction, pleurisy, acute bronchitis, acute respiratory failure, chronic obstructive pulmonary disease, and polyneuropathy. Review of the resident's physician's order revealed an order dated 03/18/19 for oxygen at three liters per minute via nasal cannula continuously. Observation of the resident on 06/03/19 at 10:43 A.M. revealed her nebulizer and oxygen tubing were both labeled with a piece of tape marked 04/19/19. Interview with Resident #40 on 06/03/19 at 10:43 A.M. revealed the staff only change her oxygen and nebulizer tubing when she requests it. Interview with Registered Nurse #230…

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

Based on record review and staff interview, the facility failed to administer medication as directed by the physician for a resident. This affected one (Resident #21) of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record of Resident #21 revealed an admission date of 11/08/11 and a readmission date of 12/29/11. Diagnoses included intracranial injury without loss of consciousness, Alzheimer's disease, anxiety, unspecified psychosis, unspecified dementia with behavioral disturbances. peripheral vascular disease, tremor, hyperlipidemia, major depressive disorder and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/08/19, revealed the resident was severely cognitively impaired. Review of the physician orders dated 01/23/19 revealed an order for gentamicin eye drops three milligrams per milliliter to be administered one to two drops in each eye twice daily for 14 days. Review of the medication administration record (MAR) for 01/2019 revealed the 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.