Westerville Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR). The facility census was 83. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 08/21/23 documented Resident #22 was at risk for changes in mood related to diagnoses of depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications as ordered,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to hold a timely admission care conference for one resident. This affected one resident (#188) of three residents sampled for care planning. The facility census was 83. Findings include: Review of Resident #188's medical record revealed an admission date of 06/03/25 and diagnoses including chronic obstructive pulmonary disease, cerebral infarction, atrial fibrillation, major depressive disorder, anxiety disorder, adjustment disorder with depressed mood, polyneuropathy, hypertension, antisocial personality disorder, and insomnia. Review of Resident #188's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #188 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Further review revealed the resident had daily verbal behaviors directed at others and rejected care daily. Review of Resident #188's physicians' orders revealed an order for two staff members to be in his room for any care or contact…

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 interview, staff interviews, personnel file reviews, record review and policy review, the facility failed to ensure activities were offered to meet the individualized needs of a resident. This affected one resident (#48) of one resident reviewed for activities. The facility census was 83. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 10/07/24. Pertinent diagnoses included: chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, chronic diastolic (congestive) heart failure, schizoaffective disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderate cognitive impairment. She needed substantial assistance for bathing and personal hygiene and was dependent on staff for toileting, lower body dressing and transfers. Review of the care plan dated 10/14/24 revealed Resident #48 was capable of pursuing independent and group…

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 revealed the facility failed to ensure a hand protector was in place for Resident #35 as ordered. This affected one resident (#35) of three residents reviewed for positioning and mobility. The facility census was 83. Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting left side, type two diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. She had a range of motion impairment of upper and lower extremity on one side. Review of Resident #35's plan of care dated 10/29/24 revealed the resident required use of splinting palm protector of left hand. She was at risk for skin irritation and or breakdown contracture. Interventions included assessing splint or brace for defects, cleansing…

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 ensure a complete investigation was completed to determine root cause analysis when a resident sustained a fall and failed to ensure fall safety interventions were in place as per residents care plan. This affected three residents (#238, #3, and #79) of the six residents reviewed for accidents and falls. Facility census was 83. Findings include: 1. Review of the medical record for Resident #238 revealed an initial admission date of 08/30/2023, a re-entry date of 11/20/2024 and a discharge date of 12/03/2024. Diagnoses included non-traumatic intracerebral hemorrhage, dementia, and hypertension. Review of Resident #238's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating an severely impaired cognition for daily decision making abilities. Resident #238 was noted to display behaviors including rejection of care. Resident #238…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to timely or accurately implement nutrition recommendations for Resident #13, #35, and #81. This affected three residents (#18, #35, #81) of seven residents reviewed for nutrition. The facility census was 83. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 09/25/21 with diagnoses including malignant neoplasm of mouth, dysphagia, protein-calorie malnutrition, adult failure to thrive, major depressive disorder (8/16/24), and unspecified psychosis. Review of Resident #18's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderately impaired cognition. Review of Resident #18's plan of care dated 03/24/25 revealed the resident had altered nutritional status as evidenced by impaired chewing ability, decreased intake of solids, refuses to eat puree and only drinks. The resident required tube feeding and supplement use. Her weight loss was unavoidable due to cancer status, refusal of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and record review the facility failed to identify and make staff aware of trauma triggers for a resident with post-traumatic stress disorder and failed to provide consistent psychosocial intervention. This affected one resident (#45) of one sampled for mood and behavior. The facility census was 83. Findings include: Review of Resident #45's medical record revealed an admission date 12/07/23 and diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, hyperlipidemia, anemia, intervertebral disc replacement lumbar region, spinal stenosis, major depressive disorder, post-traumatic stress disorder, hypertension, and heart failure. Review of Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. Review of Resident #45's physicians' orders revealed the resident was receiving the antidepressant medications Zoloft 150mg…

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 facility policy review, this facility failed to ensure controlled substances were logged or signed out in the control substance log when that medication was administered. This affected one resident (Resident #44) of the four residents reviewed during medication administration observation. The facility census was 83. Findings include: During observation completed on 06/26/2025 at 12:45 P.M. of one of the facility's four medication carts, it was noted that not all controlled substance medications were logged when the medication was removed from it packet for administration. Resident #44 was noted to have a package housing 12 tablet of the controlled substance, Lacosamide (Vimpat) 50 milligrams (mg), give one tablet two times a day. Review of the controlled substance log book for this medication cart revealed the last tablet signed out was on 06/25/2025 leaving 13 tablets Interview on 06/26/2025 at 12:48 P.M. with Licensed Practical Nurse (LPN) #112 revealed she administered one of the Vimpat tablets this morning to Resident #44 but did not sign 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 3. Review of Resident #3's medical record revealed that she was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 with foot ulcer and chronic kidney disease, malnutrition, paraplegia, discitis, borderline personality disorder and chronic pulmonary obstruction. She was alert and oriented. Review of Resident #3's clinical physician orders dated 05/30/25 revealed orders for Aspirin Oral Tablet Chewable 81 MG; give 1 tablet by mouth one time a day for hypertension, Insulin Glargine Subcutaneous Solution 100 UNIT/ML; inject 12 unit subcutaneously at bedtime for type 2 diabetes, Hydrochlorothiazide Tablet 25 MG; give 1 tablet by mouth one time a day for hypertension and edema, Ramelteon Oral Tablet 8 MG; give 1 tablet by mouth at bedtime for Insomnia and Gabapentin Capsule 400 MG; give 1 capsule by mouth three times a day for nerve pain. Review of Pharmacy Medication reviews from May 2024 to May 2025 for Resident #3 revealed no reviews for the months of July 2024, August 2024, September 2024,…

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 interviews, staff interviews, record review, policy review and safety data sheet review, the facility failed to ensure Resident #38 was free from significant medication errors. This affected one resident (#38) of one resident reviewed for medication errors. The facility census was 83. Findings Include: Record review revealed Resident #38 was admitted to the facility on [DATE]. Pertinent diagnoses included: type 2 diabetes mellitus with hyperglycemia, long term (current) use of insulin, acquired absence of right foot, acquired absence of left leg below knee, severe obesity and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #38 revealed he was cognitively intact. The functional assessment rated Resident #38 as independent on eating, hygiene, dressing and transfers, with supervision needed for showers/bathing. Review of Care Plan for Resident #38 dated 11/13/24 revealed Resident #38 was at risk for hyper/hypoglycemic reactions, abnormal lab values and diabetic…

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 facility policy review, this facility failed to ensure medication stored in the medication room and medication carts were properly labeled with an open date. This affected two residents (#33 and #243) of the four residents reviewed during medication administration. The facility census was 83. Findings include: 1. Observations completed on 06/26/2025 at 12:30 P.M. of one of the facility's two medication rooms revealed one open box with a bottle of Humulin R 3 milliliter (ml) insulin in it. The open box was noted to belong to Resident #243 who no longer resided in this facility. No open date was noted on this box. The insulin bottle stored in the box was noted to have the metal cap removed from the top of the bottle. The insulin bottle did not have an open date on it. Interview on 06/26/2025 at 12:35 P.M. with Licensed Practical Nurse (LPN) #112 confirmed there was a box of insulin with no open date being stored in the refrigerator in the medication room. LPN #112 confirmed this medication should have been dated with it was opened to ensure…

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 complete physician ordered lab tests. This affected one resident (#79) of three residents reviewed for lab tests. Findings include: Review of the medical record for Resident #79 revealed an admission date of 05/28/25, with diagnoses including chronic respiratory failure, hypertension, dissection of the ascending aorta, cerebral infarction, history of transient ischemic attack, metabolic encephalopathy, hemiplegia, and hemiparesis Review of the hospital discharge instructions dated 06/06/25 showed a requirement for a routine urine aerobic culture as part of pre-operative testing for a surgical procedure scheduled on 06/26/25. The discharge documents included a checklist for laboratory tests to be completed following transfer to the facility for a procedure. Review of the Minimum Data Set (MDS) dated [DATE] showed the resident was severely cognitively impaired, required extensive assistance for activities of daily living and is always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, the facility failed to ensure resident medical records contained information related to a resident's hospital admission. This affected one resident, (#238) of the six residents reviewed for accidents and falls. Facility census was 83. Findings include: Review of the medical record for Resident #238 revealed an initial admission date of 08/30/2023, a re-entry date of 11/20/2024 and a discharge date of 12/03/2024. Diagnoses included non traumatic intracerebral hemorrhage, dementia, and hypertension. Review of Resident #238's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating a severely impaired cognition for daily decision making abilities. Resident #238 was noted to display behaviors including rejection of care. Resident #238 was noted to be free of any impairment to his upper and lower extremities and was noted to be independent with all activities of daily living and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure enhanced barrier precautions were maintained during skin care. This affected one resident (#35) out of 16 residents on enhanced barrier precautions. The facility census was 83. Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting the left side, type 2 diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #35's physician order dated 06/17/25 revealed an order for treatment of moisture-associated skin damage to the back of the head. Staff were instructed to cleanse the area with soap and water daily and as needed, pat dry, and leave open to air. Review of physician order dated 02/18/25 required enhanced barrier precautions for high-contact…

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, staff interview, and facility policy review, the facility failed to ensure their medication error did not exceed five percent. The facility had two medication errors out of 28 opportunities resulting in a medication error rate of 7.14 percent. This affected two (Resident #30 and Resident #36) of five residents reviewed for medication administration. The census was 102. Findings include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/31/23 with diagnoses including dementia, cerebrovascular accident with right sided hemiplegia, asthma, severe protein-calorie malnutrition, multiple sclerosis, chronic obstructive pulmonary disease, anemia, metabolic encephalopathy, bipolar disorder, chronic pain, osteoarthritis, hypertension and major depressive disorder. Review of Resident #30's quarterly Minimum Data Set (MDS) assessment, dated 01/03/24, revealed Resident #30 had a moderate cognitive deficit. Review of Resident #30's monthly physician orders for March 2024 revealed an order, dated 01/30/24, for 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, review of a police report, interview with the local Fire Deputy Chief, residents and staff, review of the resident council minutes, review of emergency call records, and policy review, the facility failed to have sufficient staffing to meet the residents needs. This affected four residents (#28, #35, #58, and #109) and had the potential to affect all 104 residents currently residing in the facility. Findings include: Review of the resident council minutes dated 01/24/24 revealed call lights were not being answered timely. Review of the closed medical record revealed Resident #109 was admitted on [DATE] and discharged on 02/03/24. Diagnoses included surgical aftercare following surgery on the digestive system, colostomy, gastrostomy, protein-calorie malnutrition, anxiety, fistula of intestine, and parastomal hernia without obstruction or gangrene. Review of the case report summary from the local police (Westerville) for incident that occurred on 02/03/24 from 3:00 A.M. to 12:11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the police report, review of the Emergency Medical Services (EMS) report, review of the hospital records, review of the facility's self-reported incident (SRI), staff interview, and facility policy review, the facility failed to timely report an allegation of resident neglect to the State Survey Agency, the Ohio Department of Health. This affected one (Residents #109) of three residents reviewed for abuse. The facility census was 104. Findings include: Review of the closed medical record for Resident #109 revealed the resident was admitted to the facility on [DATE] and discharged on 02/03/24 to the hospital. Resident #109 had diagnoses including surgical aftercare following surgery on the digestive system, colostomy, gastrostomy, protein-calorie malnutrition, anxiety, fistula of intestine, and parastomal hernia without obstruction or gangrene. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the staff assessment for Resident #109…

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, resident and staff interview, and policy review, the facility failed to timely treat a resident's pressure ulcers when they were first identified. This affected one (Resident #111) of three residents reviewed for wounds. The facility census was 104. Findings include: Review of the closed medical record revealed Resident #111 was admitted on [DATE] and left the facility against medical advice (AMA) on 01/22/24. Diagnoses included spinal stenosis, type II diabetes mellitus, bipolar disorder, mood disorder, convulsions, and cervicalgia. Review of the nursing note dated 01/19/24 (Friday) at 5:01 P.M. revealed Resident #111 had a pressure wound to coccyx that measured 2.5 centimeters (cm) long and 0.7 cm wide. Resident #111 also had a pressure wound to the right upper buttock that measured 1.5 cm long and one cm wide. Resident #111 had a pressure wound to the left buttock that measured 1.5 cm long and 0.8 cm wide. Resident #111 had a scabbed wound to right groin and a pressure wound to right…

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 closed medical record review, review of a Self-Reported Incident, review of the witness statements and police report, and resident and staff interviews, the facility failed to ensure Resident #90 was treated with dignity and respect. This affected one resident (#90) of three residents reviewed for dignity and respect. The facility census was 89. Findings include: Review of the medical record revealed Resident #90 was admitted to the facility on [DATE] and discharged on 11/28/23. Resident 390 had diagnoses including cerebral infarction, aphasia, chronic pain syndrome, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had unclear speech, sometimes understood, and responded adequately to simple direct communication only. Resident #90's cognitive skills were modified independently with some difficulty in new situations and had no behaviors. Review of a facility Self-Reported Incident (SRI), tracking number 241517 dated 11/27/23 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the resident council minutes, and resident and staff interviews, the facility failed to ensure the residents were bathed according to their bathing preference. This affected two residents (#69 and #70) of three residents reviewed for bathing preferences. The facility census was 89. Findings include: 1. Review of the medical record revealed Resident #69 was admitted on [DATE] with diagnoses including fracture of right femur, anxiety, and intracranial injury with loss of consciousness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact and required extensive assistance of one staff for bed mobility and personal hygiene and extensive assistance of two staff for transfers. Review of the plan of care dated 10/26/23 revealed Resident #69 was satisfied with bathing twice a week and preferred a shower. Review of the facility's shower schedule revealed Resident #69 was scheduled to be bathed during the evening shift…

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 timely report a resident fall, timely assess Resident #61 status post fall to prevent further falls/accidents and failed to ensure the fall was documented in the resident's medical record. This affected one resident (#61) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the medical record revealed Resident #61 was admitted on [DATE] with diagnoses including malignant neoplasm of lung, acute respiratory failure, pleural effusion, and fracture of vertebra. Review of a nurse practitioner (NP) note dated 11/29/23 at 10:53 A.M. revealed Resident #61 reported they had ongoing pain in the shoulder, but it was worse after a fall on 11/28/23. There was documentation in the medical record of Resident #61 falling on 11/28/23. Review of a Fall Review form dated 11/29/23 at 1:13 P.M. revealed the NP notified the nurse that Resident #61 reported a fall that took place on 11/28/23 around 6:00 P.M. The nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the medication administration policy and procedure, and resident and staff interview, the facility failed to ensure controlled drug records and medication administration records were consistent and accurate to reflect the actual administration and accounting for controlled medications for Resident #69. This affected one resident (#69) of three residents reviewed for medications. The facility census was 89. Findings include: Review of the medical record revealed Resident #69 was admitted on [DATE] with diagnoses including fracture of right femur, anxiety, and intracranial injury with loss of consciousness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact. Review of the plan of care dated 09/25/23 revealed Resident #69 had pain/discomfort related to right femur and right tibia fracture. Interventions included administering pain medication and encouraged nonmedicinal interventions to control pain. The plan of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 12. Review of the medical record for the Resident #79 revealed an initial admission date of 01/24/23 with several trips out to the hospital. Diagnoses included encephalopathy, fracture of the upper end right humerus, fracture of the third metacarpal left hand, fracture of the fifth metacarpal left hand, muscle weakness, liver cirrhosis and seizures. Review of fall admission assessment dated [DATE] revealed residents cognitive status had changed in the previous seven days and also revealed resident was confined to a chair with no previous falls. Review of the MDS assessment dated [DATE] revealed Resident #79 was cognitively intact and required assistance from staff for mobility. Review of Occupational Therapy (OT) notes dated 07/25/23 to 08/02/23 revealed resident used the wheeled walker and wheelchair for support when ambulating. OT notes revealed resident had poor attention, short term memory, concentration and safety awareness requiring verbal cues. Review of Physical Therapy (PT) notes dated 07/25/23 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 observation, staff interview and record review facility failed to ensure pureed foods were made to the correct texture and with following the recipe. This affected five Resident (#6, #25, #70, #74, and #88) with orders for pureed food. Facility census was 92. Findings include Observation and interview on 10/04/23 at 11:53 A.M. to 12:10 P.M. revealed Dietary staff #292 made puree food for five residents (Resident #6,#25,#70,#74, and #88). Dietary staff revealed she aimed for a mashed potato consistency for pureed food. She revealed for the rice she started a ½ cup scoop for each serving and made six servings with about ½ cup of water. She then added two tablespoon scoops of thickener. Dietary staff stated she thought this was a good consistency. Surveyor asked to do a taste test for texture and taste and dietary staff completed taste test and stated oh that tastes like paste. The texture was gummy and sticky with full grains of rice still present and visible. Dietary staff then added another ½ cup of water to loosen it up. She then blended the mixture and a second taste test…

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 one resident's indwelling urinary catheter collection bag was contained in a privacy bag. This affected one (Resident #52) of one reviewed for indwelling urinary catheter. The facility census was 92. Findings Include: Review of the medical record for Resident #52 revealed an initial admission date of 07/08/23 with the most recent readmission of 07/24/23 with diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for bed mobility, transfers, and toilet use. The assessment indicated the resident was always incontinent of bowel and bladder.…

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 one resident (#28) had a physician's order and was assessed for self-administration of medication. This affected one (Resident #28) of three residents observed for medication administration. The facility census was 92. Findings Include: Review of the medical record for Resident #28 revealed an initial admission date of 03/04/23 with the latest readmission of 07/14/23 with diagnoses including diabetes mellitus, cardiomyopathy, congestive heart failure, hyperlipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, hypertension, end stage renal disease, dependence on hemodialysis and gout. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairment. Review of the monthly physician orders for October 2023 identified orders dated 07/18/23 Fluticasone Propionate nasal suspension 50 micrograms (mcg) with the special instructions to spray two sprays in each…

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, interviews and facility policy review, the facility failed to ensure one resident (#1) was bathed per their preference and one resident (#79) was dressed per their preference. This affected two ( Resident #1 and #79) of five residents reviewed for choices. The facility census was 92. Findings Include: 1. Review of the medial record for Resident #1 revealed an initial admission date of 04/27/23 with diagnoses including pneumonia, metabolic encephalopathy, dysarthria, dementia, depression, cerebral infarction, osteoarthritis, dysphagia, generalized muscle weakness and repeated falls. Review of the plan of care dated 07/13/23 revealed the resident had a self-care performance deficit related to CVA and dementia. Interventions included staff to assist with activities of daily living (ADL) as needed, monitor for fatigue and provide rest periods as needed and reassess quarterly and as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] 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.

Based on observation, record review, and interview, the facility failed to ensure two resident's (#5 and #52) room was free of a persistent odor of urine. This affected two (Resident #5 and #52) of seven residents reviewed for environmental concerns. The facility census was 92. Findings Included: 1. On 10/02/23 at 11:12 A.M., observation of Resident #52 revealed the resident had an indwelling urinary catheter. The resident's room had a strong odor of urine. Interview with Resident #52 revealed she could smell the odor of urine in her room and the smell bothered her. Resident #52 revealed she requested the indwelling urinary catheter collection bag be changed but to date had not been changed. On 10/02/23 at 3:35 P.M., observation of Resident #52's room revealed the room continued to have a strong odor of urine. Interview with State Tested Nursing Assistant (STNA) #265 verified at the time of the observation the resident's room had a persistent strong odor of urine. 2. On 10/02/23 at 3:40 P.M., observation of Resident #5's room revealed the room had a strong persistent odor of urine.…

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 report a suspected crime to local law enforcement. This affected one (Residents #16) of five resident incidents reviewed. The census was 92. Findings Include: Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. Review of Resident #16 medical records, which included progress notes, care plans, and investigation reports, revealed nothing to support her…

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 report alleged incidents in a timely manner. This affected two (Residents #16 and Resident #45) of five resident incidents reviewed. The census was 92. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. Review of Resident #16 medical records, which included progress notes, care plans, and investigation reports, revealed nothing…

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 investigate an allegation of misappropriation. This affected one (Residents #16) of five resident incidents reviewed. The census was 92. Findings Include: Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. Review of Resident #16 medical records, which included progress notes, care plans, and investigation reports, revealed nothing to support her…

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 perform an accurate discharge assessment. This affected one (Resident #92) of three resident discharges reviewed. The census was 92. Findings Include: Resident #92 was admitted to the facility on [DATE]. His diagnoses were diverticulitis, type II diabetes, other chronic pain, hyperlipidemia, hypertension, arthrogryposis multiplex congenital, cognitive communication deficit, muscle weakness, depression, and vitamin D deficiency. Review of his minimum data set (MDS) assessment, dated 06/29/23, revealed he was cognitively intact. Review of Resident #92 MDS assessment section A, dated 08/03/23, revealed the facility documented he was discharged to a hospital. Review of Resident #92 progress notes, dated 08/04/23, revealed Resident #92 left the faciity on a leave of absence. It was documented that he had not returned to the facility in more than 24 hours, so he was discharged . There was no documentation to support at the time of discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to revise comprehensive care plans for two residents (Residents #45 and #83). This affected two residents (Residents #45 and #83) out of 24 reviewed for comprehensive care plans. The facility census was 92. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date on 08/14/23. Medical diagnoses included displaced fracture of the posterior wall of right acetabulum, fracture of right acetabulum, fracture of upper end of left humerus, subluxation of right hip, type II diabetes mellitus with chronic kidney disease, mild intellectual disabilities, and difficulty in walking. Review of the Medicare Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #45 requested extensive assistance from two staff for bed mobility and total dependence from two 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, interviews, and policy review, the facility failed to ensure three residents (#1, #5 and #61) who were dependent on staff for bathing received scheduled showers and according to preference. This affected three (Resident #1,#5, and #61) of three residents reviewed for activities of daily living (ADLs). The facility census was 92. Findings Included: 1. Review of the medical record for Resident #61 revealed an admission date of 06/01/21 with diagnoses including unilateral primary osteoarthritis of the left knee, generalized muscle weakness, reduced mobility, cerebral infarction, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had intact cognition. Resident #61 required extensive one person assistance for personal hygiene. Review of the recreation progress note and assessment dated [DATE] revealed it is very important for Resident #61 to choose which type of bath he wants to take. When choosing between a bed bath or…

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, resident and staff interviews and record review, facility failed to ensure meaningful activities were offered and provided. This affected one Resident (#146) of three reviewed for activities. Facility census was 92. Findings include Review of the medical record for the Resident #146 revealed an admission date of 09/22/23. Diagnoses included syncope and collapse, diabetes type two, kidney failure, hemiplegia, and muscle weakness. Review of the not completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. Review of the plan of care dated 09/25/23 revealed Resident #146 had potential for decreased activity participation, involvement and/or social isolation related to immobility with interventions: if resident chooses to not attend organized activities, turn on TV or music or provide sensory stimulation and invite resident to attend scheduled activities. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to comprehensively assess one resident's (#78) Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer on admission, readmission and weekly there after. This affected one (Resident #78) of two residents reviewed for pressure ulcers. The facility census was 92. Findings Included: Review of the medical record for Resident #78 revealed an initial admission date of 03/21/23 with the latest readmission of 08/02/23 with diagnoses including disease of digestive system, osteomyelitis, diabetes mellitus, cerebrovascular accident (CVA) with right sided hemiplegia, obstructive and reflux uropathy, moderate protein calorie malnutrition, seizures, stage IV pressure ulcer to sacral region, chronic pancreatitis, anemia and hypertension. Review of the admission/re-admission evaluation dated 03/21/23 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 observation, resident and staff interview, record review, and facility policy review, the facility failed to administer a nutritional supplement to one resident (Resident #83) as ordered. This affected one resident (Resident #83) of six residents reviewed for nutrition. The facility census was 92. Findings Include: Review of the medical record for Resident #83 revealed an admission date on 08/29/23. Medical diagnoses included hypertensive heart disease with heart failure, dehydration, congestive heart failure (CHF), muscle weakness, and history of falling. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #83 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #83 was noted to have a weight loss of 5% or more in the last month and was on a therapeutic diet. 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, record review, interview and facility policy review, the facility failed to ensure residents had physician's orders in place for dialysis and monitoring of dialysis sites. This affected two ( Resident #28 and #52) of two residents reviewed for dialysis. The census was 92. Findings Included: 1. Review of the medical record for Resident #52 revealed an initial admission date of 07/08/23 with the most recent readmission of 07/24/23 with diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident received dialysis. Review of the monthly physician's orders for October 2023 failed to identify physician's orders for dialysis,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to administer as needed pain medication within parameters as ordered by the physician and failed to attempt non-pharmacological interventions prior to administering as needed pain medication for one resident (Resident #4). This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 92. Findings Include: Review of the medical record for Resident #4 revealed an admission date on 08/31/23. Medical diagnoses included hemiplegia and hemiparesis following stroke affecting right dominant side, dementia without behavioral disturbance, and chronic pain. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #4 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, and record review, the facility failed to ensure medications were not left out at bedside without secure storage and supervision from the nurse. This affected two residents (#28 and #146) of two reviewed for medication storage. Facility census was 92. Findings include 1. Review of the medical record for the Resident #146 revealed an admission date of 09/22/23. Diagnoses included syncope and collapse, diabetes type two, kidney failure, hemiplegia, and muscle weakness. Review of the not yet fully completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. Review of the medical record revealed no evidence of resident having been assessed to self-administer medications. Observation and interview on 10/04/23 at 1:30 P.M. with State Tested Nursing Aide (STNA) #263 and Resident #146 revealed STNA was overheard informing resident your meds…

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 Resident #17 was properly issued a 30 day discharge notice and failed to ensure Resident #17 reviewed his discharge summary. This affected one resident (Resident #17) of four residents reviewed for discharges. Findings Include: Resident #17 was admitted to the facility on [DATE]. His diagnoses were alcoholic cirrhosis of liver without ascites, hypertension, anorexia, other idiopathic peripheral autonomic neuropathy, muscle weakness, and difficulty walking. According to his medical documentation, he was his own responsible party with a family member as the first emergency contact. Review of Resident #17's 30 day discharge letter, revealed the letter was generated on 01/09/20 due to the facility stating they were not able to meet the residents needs, and he was to be discharged on 02/10/20. There was no evidence the letter was issued to Resident #17. Review of Resident #17 medical documentation revealed he was discharged 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.

Based on medical record review and staff interview, the facility failed to provide evidence that the state ombudsman was notified of resident discharges. This affected three residents (Resident #17, Resident #88, and Resident #89) of four resident discharges reviewed. Findings Include: Review of Resident #17 medical records revealed he was immediately discharged from the facility on 02/24/20, after he was arrested. Review of Resident #88 medical records revealed she was discharged from the facility on 07/16/21, when she was sent to the hospital. Finally, review of Resident #89 medical records revealed she was discharged home immediately on 08/10/21. While reviewing all three resident medical records, there was no evidence that the facility sent the discharge information to the state long term care ombudsman office. Interview with Administrator on 09/30/21 at 1:15 P.M. confirmed that the facility could not produce evidence they sent the monthly discharges to the state long term care ombudsman's office. She stated they could look through historical documentation, but it could 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 observations, staff interview, record review, and facility policy review, the facility failed to ensure two residents (Residents #1 and #60) had their hair washed as scheduled and failed to ensure one resident (Resident #62) was shaved per preference. The affected three residents (Residents #1, #60, and #62) of five residents reviewed for activities of daily living (ADL's). Findings Include: 1. Review of the medical record for Resident #1 revealed an original admission date of 01/21/21 and a readmission date on 09/16/21 with medical diagnoses including addisonian crisis, stage III chronic kidney disease, other specified sepsis, muscle weakness, type II diabetes mellitus, encephalopathy, disorientation, adult failure to thrive, low back pain, fibromyalgia, rheumatoid arthritis, anxiety disorder, major depressive disorder, and other abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21, revealed Resident #1 had mildly impaired cognition and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide activities according to Resident #44 and Resident #338's preferences. This affected two residents (Resident #44 and Resident #338) of two residents reviewed for activities that meet the interest and needs of each resident. Findings include: 1. Record review revealed Resident #338 was admitted to the facility on [DATE] with diagnoses including type two diabetes with hyperglycemia, vascular dementia with behavioral disturbance, major depressive disorder, unsteadiness on feet, muscle weakness and other abnormalities of gait and mobility. Review of Resident #338's comprehensive Minimum Data Set (MDS) assessment, dated 09/23/21, revealed the resident was cognitively impaired and required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #49's progress notes. dated 09/20/21, Activities Director (AD) #168 documented the resident enjoyed music, singing, sewing, sitting on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure a splint was placed on a resident's (Resident #46) left hand as ordered. The deficient practice affected one (Resident #46) of one reviewed for limited range of motion (ROM). Findings Include: Review of the medical record for Resident #46 revealed an admission date on 06/22/18 with medical diagnoses including cerebral infarction, cognitive communication deficit, aphasia following unspecified cerebrovascular disease, weakness, other lack of coordination, and muscle weakness. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/19/21, revealed the resident was rarely or never understood. Per staff assessment, the resident had severely impaired cognition. The resident required extensive assistance to total dependence on staff to complete activities of daily living (ADL's). Review of the current physician orders for Resident #46 revealed an order with a start date on 10/28/20…

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, interview, and facility policy and procedure, the facility failed to ensure fall interventions were in place and revised as needed. This affected two residents (Resident #25 and Resident #62) out of four residents reviewed for falls. Findings Include: 1. Review of the medical record for Resident #25 revealed an admission date of 05/17/11 with the diagnoses of falls, ataxia, lack of coordination and gait abnormalities. Review of Resident #25's Minimum Data Set (MDS) assessment, dated 07/16/21, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and she required extensive one assistance for bed mobility, dressing, toilet use and transfers, independence for locomotion via wheelchair, and supervision of one assist for personal hygiene. Review of Resident #25's fall investigations revealed the following: A. On 10/07/20 at 11:00 A.M. the resident was transferring from the bed to the wheelchair and lost balance. The resident was educated and encouraged to call for assistance when needed to prevent falls. B. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a resident had physician orders for the use of respiratory equipment referred to as a Continuous Positive Airway Pressure (CPAP) machine. This affected one resident (Resident #340) of two residents reviewed for respiratory care. Findings include: Record review for Resident #340 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to obstructive sleep apnea, end stage renal disease, type two diabetes with unspecified diabetic retinopathy, and cognitive communication deficit. Review of Resident #340's comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired and required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review of resident #340's medical record revealed an inventory of personal effects form dated 09/15/21 indicating the resident was admitted to the facility with a CPAP…

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 interview, medical record review, and facility policy review, the facility failed to communicate and review dialysis labs for Resident #82. This affected one resident (Resident #82) of three residents reviewed for dialysis services. Findings include: Review of the medical record for Resident #82 revealed an admission date of 08/23/13 and readmission date of 09/03/21 with diagnosis including dependent on renal dialysis, type two diabetes mellitus, pulmonary edema and congestive heart failure. The resident received renal dialysis three times per week on Tuesday, Thursday and Saturday at a local dialysis center. Review of the active plan of care for dialysis revealed interventions included obtain lab values and notify physician. Review of the Nurse Practitioner (NP) documentation on 07/09/21 revealed the resident refused to have labs drawn at the facility and the order was sent to dialysis to obtain labs there if possible. Resident #82 stated he would not have any blood drawn at the facility because he had blood work all the time at dialysis. Review of the lab results 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.

Based on resident and staff interview, review of laboratory results, and record review, the facility failed to notify the physician or certified nurse practitioner (CNP) of new urinalysis test results for Resident #1. This affected one resident (Resident #1) of one resident reviewed for notification of change. Findings Include: Review of the medical record for Resident #1 revealed an original admission date of 01/21/21 and a readmission date on 09/16/21 with medical diagnoses including addisonian crisis, stage III chronic kidney disease, other specified sepsis, type II diabetes mellitus without complications, and urinary tract infection (UTI) with site not specified. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21, revealed Resident #1 had mildly impaired cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete activities of daily living (ADLs), including toileting. The resident did not have a catheter and was always incontinent of both…

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 Resident #86's medical record reflected an accurate diagnosis for physician ordered medication. This affected one resident (Resident #86) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #86 revealed an admission date of 09/06/21. Diagnosis included age-related cognitive decline, abnormalities of gait and mobility, and disease of esophagus. Review of the admission Minimum Data Set (MDS) 3.0, assessment, dated 09/13/21, revealed the resident was noted with a ok long and short term memory and was independent for decisions regarding tasks of daily living. No behaviors were noted at this time. Resident #86 required extensive assistance from two staff members for bed mobility, and toilet use, and extensive assistance from one staff member for dressing, and personal hygiene. Resident #86 required the use of a indwelling catheter for bladder elimination and was continent of bowel elimination. Review of the physician orders for September 2021…

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

Based on observation, interview, and record review, the facility failed to maintain infection control after a blood glucose check and during insulin administration. This affected one resident (Resident #80) out of two residents observed during medications administration for blood glucose checks and insulin administration. Findings Include: Review of the record for Resident #80 revealed an admission date of 06/01/21 and the diagnoses of diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), anxiety, depression, insomnia, atrial fibrillation, opioid dependency, and chronic pain. The resident had no documented evidence of a transmissible disease. Review of Resident #80's Minimum Data Set (MDS) assessment. dated 09/08/21, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and the resident required extensive assistance of one staff for bed mobility, personal hygiene, and toilet use, and supervision one assist for transfers and walking. Review of Resident #80's September 2021 physician orders revealed orders for Lispro insulin per blood…

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.