Life Care Center Of Westlake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, resident interview, staff interviews, Self-Reported Incident (SRI) review, and facility policy review, the facility failed to report an allegation of verbal abuse. This affected one resident (#20) of three residents reviewed for verbal abuse. The facility census was 99.Findings include:Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented to person, place and time and was modified independent for tasks regarding daily life.Review of the care plan dated 12/03/25 revealed Resident #20 had a behavior problem related to refusal of care and medications and was accusatory toward staff. Interventions included, but was not limited to, allowing Resident #20 to verbalize her needs, two staff present for all care, and observing for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, resident interview, staff interviews, Self-Reported Incident (SRI) review, and facility policy review, the facility failed to respond appropriately to an allegation of verbal abuse. This affected one resident (#20) of three residents reviewed for verbal abuse. The facility census was 99.Findings include:Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented to person, place and time and was modified independent for tasks regarding daily life. Review of the care plan dated 12/03/25 revealed Resident #20 had a behavior problem related to refusal of care and medications and was accusatory toward staff. Interventions included, but was not limited to, allowing Resident #20 to verbalize her needs, two staff present for all care, 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 review of employee personnel files, staff interviews, and facility policy review, the facility failed to ensure three of five sampled staff members were certified in Cardio-Pulmonary Resuscitation (CPR). This had the potential to affect all residents residing in the facility. The facility census was 99.Findings include: 1. Review of the personnel file for Certified Nursing Assistant (CNA) #445 revealed she was hired on [DATE]. CNA #445 had no current CPR certification.Interview on [DATE] at 3:20 P.M. with CNA #445 revealed she was not currently certified in CPR. CNA #445's CPR certification expired in [DATE].2. Review of the personnel file for Registered Nurse (RN) #301 revealed she was hired on [DATE]. RN #301 had no current CPR certification.Interview on [DATE] at 3:25 P.M. with RN #301 revealed she was not currently certified in CPR. RN #301's CPR certification expired in [DATE].3. Review of the personnel file for Licensed Practical Nurse (LPN) #312 revealed she was hired on [DATE]. LPN #312 had no…

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

Based on review of employee personnel files and staff interviews, the facility failed to ensure two of five staff members received annual performance reviews. This had the potential to affect all residents residing in the facility. The facility census was 99.Findings include: 1. Review of the personnel file for Certified Nursing Assistant (CNA) #445 revealed she was hired on 09/24/20. CNA #445 did not have a current annual performance review in place.Interview on 12/11/25 at 3:20 P.M. with CNA #445 revealed she did not have a current annual review completed.2. Review of the personnel file for CNA #331 revealed she was hired on 06/24/11. CNA #331 did not have a current annual performance review in place.Interview on 12/11/25 at 3:30 P.M. with the Director of Nursing (DON) confirmed CNAs #331 and #445 did not have annual performance reviews in place. The DON verified both CNAs were still currently on the schedule and actively working shifts throughout the facility. After evidence of annual performance reviews was requested, the DON stated that CNA #445 was currently actively…

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 administer medications according to physician orders and manufacturer instructions. This affected two residents (#16 and #21) out of three residents reviewed for medication administration. The facility census was 99.Findings include:1. Observation of a medication administration pass for Resident #16 on 12/09/25 at 10:00 A.M. by Registered Nurse (RN) #301 revealed the nurse drew one pill out of a digoxin 125 microgram (mcg) container which had attached pharmacist instructions to hold the medication if the heart rate was under 60 beats per minute (BPM). The nurse administered the medication without checking the resident's heart rate.Record review of Resident #16 revealed an order dated 11/27/25 for 125 mcg of digoxin to be given daily for heart failure, and to hold the dose for a heart rate under 60 BPM.Interview on 12/09/25 at 10:08 A.M. with RN #301 confirmed the above findings, and verified Resident #16's heart rate was not checked prior to medication administration. Observation at the time of the interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review, the facility failed to monitor Resident #97 for injuries after a fall. This affected one resident (#97) of three resident injuries reviewed. The facility census was 94. Findings Include: Resident #97 was admitted to the facility on [DATE] with diagnoses including dementia, depression, insomnia, drug induced subacute dyskinesia, mixed hyperlipidemia, urinary incontinence, and constipation. Review of the Minimum Data Set (MDS) assessment, dated 12/08/24, revealed Resident #97 had severe cognitive impairment. Review of the progress notes, dated 12/05/24, revealed Resident #97 was found with her knees on the ground, legs out of her bed, and head/torso still lying on her bed. Staff documented that there was discoloration to Resident #97's knees and a small area to her right elbow. There was no other documentation to describe what the injuries/areas looked like. Review of Resident #97 medical records, including bath/shower records, skin…

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 facility investigation, review of email documents, review of self-reported incidents (SRIs), and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#75) of four residents reviewed for misappropriation. The facility census was 95. Findings Include: Review of Resident #75's medical record revealed an admission date of 03/08/24. Diagnoses included chronic obstructive pulmonary disease (COPD), pneumonia and epilepsy. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 was cognitively intact and required one-person physical assistance for his activities of daily living. Further review of the medical record revealed Resident #75 was discharged to a nursing facility closer to his family on 07/15/24. Review of a self-reported incident dated 07/10/24 revealed, on 7/10/24, a detective visited the facility to discuss an investigation that was occurring with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review the facility failed to ensure an allegation of staff to resident abuse was reported to the state agency as required. This affected one resident (#80) of three residents reviewed for abuse. The facility census was 102. Findings Include: Resident #80 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, dementia with other behavioral disturbance, generalized anxiety disorder, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had moderately impaired cognition and was independent for ambulation. Interview on 02/29/24 at 10:00 A.M. with Human Resources Director (HR) #204 revealed that there was an incident this past weekend that involved Resident #80 and a dietary staff member. HR #204 stated that he is investigating the incident of Dietary Aide (DA) #214 holding a resident's wrist, but it wasn't abuse. Interview on 02/29/24 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 record review and interviews the facility failed to ensure physician orders were followed to hold Resident #100's tube feed in preparation for a dentist appointment. This affected one resident (Resident #100) of three reviewed for quality of care. Findings include: Record review of Resident #100 revealed an initial admission date of 04/04/19 and readmission of 07/29/23. She was discharged on 02/02/24. Diagnoses included metabolic encephalopathy, anoxic brain damage, pneumonia and sepsis. Review of the progress noted dated 01/09/24 at 10:38 A.M. revealed the resident's tube feeding was to be stopped at midnight related to dental appointment on 01/15/24. Review of Resident #100's physician orders for 01/14/24 revealed the resident was to be NPO (nothing by mouth) after midnight and the tube-feed was to be held. Review of the Medication Administration Record for January 2024 revealed the order for NPO status on 01/14/24 was signed off by Licensed Practical Nurse (LPN) #223. Interview on 02/06/24 at 1:18 P.M. with LPN #223 revealed she was told Resident #100 had an appointment…

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 and record review, the facility failed to ensure Resident #29 received adequate foot care to regularly trim toenails. This affected one resident (Resident #29) out of three residents reviewed for foot care. Findings include: Record review of Resident #29 revealed an admission date of 10/07/22. Diagnoses included Alzheimer's Disease, major depressive disorder and diabetes mellitus type 2. Review of Resident #29's medical record including Certified Nurse Practitioner's monthly notes from August 2023 through February 2024 revealed no indication the resident's toenails were trimmed or evidence the resident was assessed for podiatry needs. There was no indication of refusals or attempts to cut the resident's toenails. Interview on 02/05/24 from 10:00 A.M. to 10:17 A.M. with Licensed Practical Nurse (LPN) #203 and LPN #205 revealed they did not believe Resident #29 was seen by a podiatrist. They stated a podiatrist would need to cut the resident's toenails because they were diabetic. Interview on 02/05/24 at 10:13 A.M. with Certified Nurse Practitioner (CNP) #225 stated…

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

Based on record review and interviews the facility failed to ensure Resident #100's medical record accurately reflected NPO (nothing by mouth) status. This affected one of three residents reviewed (Resident #29 and Resident #95). The census was 95. Findings include: Record review of Resident #100 revealed an initial admission date of 04/04/19 and readmission of 07/29/23. She was discharged on 02/02/24. Diagnoses included Metabolic encephalopathy, anoxic brain damage, pneumonia and sepsis. Review of the orders for Resident #100 revealed the resident was to be NPO (nothing by mouth) after midnight and the tube-feed was to be held. The order was signed off by Licensed Practical Nurse (LPN) #223. Interview on 02/06/24 at 1:18 P.M. with LPN #223 revealed she said she was only working four hours that day. She stated she was told Resident #100 had an appointment the next morning but was not told about the NPO status. LPN #223 stated she was told to sign off on orders early to make it easier for next person covering the shift. She did not recall who told her this. She stated she overlooked…

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

Based on observation and staff interview the facility failed to ensure food was labeled and dated properly and was stored in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect 95 of 96 residents who received meals from the kitchen. The facility identified one resident (#8) who received nothing by mouth (NPO). Findings include: During the initial kitchen tour conducted on 10/16/23 from 9:03 A.M. through 9:28 A.M. revealed the following: • Two full packages of hot dog buns were dated use by 10/09/23. • In the deli cooler there was a package of undated shaved turkey and a container of shredded lettuce that was brown/slimy at the bottom. • In the freezer there was a plastic bag with ten pieces of breaded fish not labeled or dated. • The microwave had food spilled inside. These findings were verified by Dietary Manager #883 at the time of the observations.

Based on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect 95 of 96 residents who received meals from the kitchen. The facility identified one resident (#8) who received nothing by mouth (NPO). Findings include: Observation of the facilities garbage disposal area with Dietary Manager #883 on 10/16/23 at 9:20 A.M. revealed side doors to two dumpsters were open and garbage bags were protruding out the sides. There was some trash around the dumpster such as plastic cups, plastic gloves, dirt, and leaves. These observations were verified by Dietary Manager #883 at the time of the observation. An additional observation on 10/18/23 at 1:11 PM. bags of trash hanging out of the dumpster was verified by the Administrator at 1:26 PM.

Based on observation, review of the facility insulin storage parameters, and interview, the facility failed to ensure insulin containers were labeled with opening dates to ensure they were not used beyond their recommended expiration. This affected four of four residents with insulin stored on the 200-hall medication cart (Resident's #34, #97, #9, and #30). The facility census was 96. Findings include: Observation of the unrefrigerated 200-hall medication cart on 10/16/23 at 4:50 P.M. revealed insulin injection pens had no date of opening recorded either on the pens or the plastic bags they were stored in. This affected two of two insulin pens for Resident #34, two of three pens for Resident #97, one of one pen for Resident #9, and one of one pen for Resident #30. Interview with Registered Nurse (RN) #891 on 10/16/23 at 4:50 P.M. confirmed the above findings, and that she could not identify what date the pens were opened. Record review of the facility's undated insulin storage parameters revealed insulin could only be stored at room temperature for a certain number of days 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 record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were provided to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected three residents (#38, #69, and #98) of three residents reviewed for appropriate beneficiary notices. Findings include: Review of the beneficiary notice worksheet provided by the facility during the annual survey revealed the following: 1. Resident #38 was discharged from skilled therapy services while using their Medicare Part A benefit on 05/18/23. Resident #38 remained in the facility after discharge. 2. Resident #69 was discharged from skilled therapy services while using their Medicare Part A benefit on 05/31/23. Resident #69 remained in the facility after discharge. 3. Resident #98 was discharged from skilled therapy services while using their Medicare Part A benefit on 05/05/23. Resident #98 remained in the facility after discharge. Review of the notices provided to Resident's #38, #68, and #98 upon discontinuation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure a valid level one pre-admission screen and resident review (PASRR) was completed prior to Resident #26's admission to the facility from a community setting. This affected one resident (#26) of three residents reviewed for PASRR. The facility census was 96. Findings include: Resident #26 was admitted to the facility on [DATE] from home with diagnoses including major depressive disorder, anxiety disorder, dementia, and post-traumatic stress disorder. Review of Resident #26's PASRR records revealed a PASRR was completed on 04/07/22 by Residents #26's community case management agency. The form noted she was admitting the resident to the facility from a community setting. Licensed Social Worker (LSW) #845 verified that Resident #26's PASRR was not completed prior to admission as required during an interview on 10/19/23 at 10:30 A.M.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide care and services to diagnose and treat a suspected urinary tract infection (UTI) in a timely manner for Resident #43. This affected one resident (#43) of one resident reviewed for UTIs. The facility census was 96. Findings include: Review of the medical record for Resident #43 revealed an admission date of 09/09/21 with diagnoses including need for assistance with personal care, overactive bladder, anxiety disorder, and chronic diastolic congestive heart failure. Review of the Urinary Incontinence Tool assessment dated [DATE] revealed Resident #43 had urge incontinence and would try to use restroom. Resident #43 was reported to have a history of UTIs with historical symptoms including confusion and lethargy. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #43 had Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition. Resident #43 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #5's elopement events were submitted as self-reported incidents to the Ohio Department of Health incident tracking website. This affected one (Resident #5) of three residents reviewed for elopement. The total census was 99. Findings include: Record review of Resident #5 revealed he was admitted to the facility 07/13/21 and had diagnoses including dementia, alcohol abuse, and major depressive disorder. A probate physician assessment dated [DATE] revealed he had severe cognitive, judgement, insight, and memory deficits which rendered him incapable of self-management of person and estate. He had a court-ordered guardian in place as of 12/23/21. Review of his minimum data set assessment on 06/20/23 revealed he refused to complete a mental status assessment and required supervision assistance for transfers and locomotion. He was assessed as having verbal behaviors four to six of seven days and rejection of care one to three of seven days.…

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 prevent two elopement events by Resident #5. This affected one (Resident #5) of three residents reviewed for elopement. The total census was 99. Findings include: Record review of Resident #5 revealed he was admitted to the facility 07/13/21 and had diagnoses including dementia, alcohol abuse, and major depressive disorder. A probate physician assessment dated [DATE] revealed he had severe cognitive, judgement, insight, and memory deficits which rendered him incapable of self-management of person and estate. He had a court-ordered guardian in place as of 12/23/21. Review of his minimum data set assessment on 06/20/23 revealed he refused to complete a mental status assessment and required supervision assistance for transfers and locomotion. He was assessed as having verbal behaviors four to six of seven days and rejection of care one to three of seven days. His elopement risk assessment dated [DATE] revealed he was at risk for elopement due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure staff washed/sanitized their hands appropriately during medication administration for Resident #20 and failed to don appropriate personal protective equipment and handle laundry appropriately during wound care for Resident #68. This affected one out of three residents observed for medication administration and one out of two residents observed for wound care (#20 and #68). The facility census was 105. Findings include: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, polyneuropathy, hypertensive heart disease, osteoarthritis, lymphedema, bipolar disorder, anxiety, diverticulosis, urinary tract infection, heart arrhythmias, irritable bowel syndrome and hyperlipidemia. A review of Resident #20's physician orders dated 08/01/23 to 08/31/23 indicated to administer acetaminophen 500 milligrams (mg) orally three times a day, vitamin D 100 micrograms (mcg) orally in the 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.

Based on observation, record review and interview the facility failed to maintain the kitchen in clean and sanitary conditions and ensure handwashing was performed during food preparation to prevent potential contamination and/or food borne illness. This had the potential to affect all 113 residents residing in the facility with the exception of Resident #41 who received nothing by mouth. Findings include: 1. Tour of the kitchen on 02/24/20 from 8:36 A.M. to 8:53 A.M. with Dietary Director (DD) #300 revealed the stove had black buildup that appeared to be hard black grease between the eyes of the stove and near the griddle which also has black grease buildup. The convection oven had various food splatters, possibly grease. The blade of the commercial can opener had caked on blackish buildup. The reach in cooler on the right side of the wall closer to the dish room there was various crumbs and food splatter on the inside bottom shelf of the cooler and on the outside of the bottom portion of the cooler. The scoops for the containers that housed the bulk flour, rice, and sugar were…

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 observation, record review and interview the facility failed to ensure privacy was provided for Resident #99 during a physical assessment. This affected one resident (#99) of 38 residents residing on the 600 Hall with the exception of Resident #41 who does not eat in the dining room. Findings include: Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including dementia, receptive-expressive language disorder and hypertension. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderate cognitive deficits with disorganized thinking. On 02/26/20 beginning a 11:50 A.M., a meal observation was made in the 600 Hall dining room. At 12:09 P.M., two women, one with a stethoscope around her neck approached Resident #99 who was seated in the dining room. One of the ladies asked to look at the resident's legs for swelling. After Resident #99 lifted her pants legs, one of the women assessed the resident's legs. One 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 interview and record review the facility failed to timely reach a resolution to resident concerns regarding call lights. This affected 18 residents, Resident #102, Resident #49, Resident #35, Resident #254, Resident #98, Resident #94, Resident #48, Resident #86, Resident #79, Resident #60, Resident #10, Resident #87, Resident #16, Resident #18, Resident #92, Resident #50, Resident #42, Resident #80, of 18 residents that attended the resident group meeting .It had the potential to affect previous meeting attendee with concerns not resolved. The facility census was 105. Findings include: Interview on 01/14/19 at 1:39 P.M. with residents in the resident group meeting revealed the resident council has brought up concerns regarding call lights for the last ten months and have not gotten a response until two weeks ago. During the meeting Resident #48 stated the call light response time is delayed because the facility was short staffed. Resident #80 stated she had to wait 50 minutes last night for assistance…

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 notify the Long-Term Care Ombudsman of Resident #43 transfer to the hospital within 30 days of hospitalization. This affected one (Resident #43) of one residents reviewed for hospitalization, with the potential to affect nine (Resident # 16, Resident #17, Resident #73, Resident #102, Resident #9, Resident #42, Resident #77, Resident #89, and Resident #104) of ten residents that were transferred to the hospital from [DATE] through December 2018. The facility census was 105. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including heart failure, altered mental status, bipolar disorder, depression, and diabetes mellitus. She was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Interview with Licensed Social Worker (LSW) #106 on 01/15/19 at 3:16 P.M. revealed the facility was not notifying the Long-Term Care Ombudsman of residents being transferred 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, interview and record review, the facility failed to ensure tuberculin vials were dated. This affected two out of three vials of tuberculin solution in one of two medication rooms and had the potential to affect any of the seven residents (#97, #153, #253, #254, #303, #304 and #305) who were admitted in the facility for the past 30 days and use insulin. The facility census was 102. Findings include: Observation of the medication room in the locked unit on 1/16/19 at 12:50 P.M. with Licensed Practical Nurse (LPN) #100 revealed two boxes of tuberculin solution for Mantoux (tuberculosis) testing not dated when the vials were opened. LPN#100 confirmed the findings and stated she knew the vials should be dated when opened. Review of the facility policy, Medication Storage Parameters in the facility, revised 03/31/2017, revealed vials should be dated when opened and discharged 30 days after opening. The Director of Nursing confirmed on 01/16/18 at 2:05 P.M. multi use tuberculin vials should be dated when opened and discarded 30 days after opening.

Based on observation, record review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, that milk was stored to prevent contamination and food products were dated when opened. This had the potential to affect 103 out of 105 residents who ate meals in the facility's kitchen. Findings include: Observations during the initial tour of the kitchen on 01/13/19 from 8:11 A.M. through 8:50 A.M. with [NAME] #104 revealed that a bag of danishes and diced chicken in the walk-in freezer were not labeled and dated; breakfast gravy in the walk-in refrigerator was not labeled or dated; the wall behind the coffee machine had food splatter on it; the wall as you come into the kitchen had food splatter on it; two food carts that went to the floors had food residue inside and outside of them; the bins of sugar, flour and rice were not dated plus had scoops inside the bins touching the product and one trash can out of four in the kitchen had a lid on it. The dish area revealed that there was a Styrofoam bowl, plastic medicine cup and food debris under…

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, observation and record review the facility failed ensure proper handwashing procedures during Medication Administration. This affected one resident (Resident #9) of three Residents (Resident #9, #39 and #98) observed for medication administration and had the potential to effect 15 Residents (Resident #1, #8, #9, #15, #43, #56, #58, #72, #74, #76, #85, #87,#91, #101, #305) who receive medication administered by a nurse in the 200 hallway. The facility also failed to ensure proper disinfection of the glucometer devise. This affected one resident (Resident # 63) who received accuchecks, blood sugar reading, and had the potential to effect six Resident (Resident #53, #73, #89, #95, #99 and #253) who ordered accuchecks. The facility census was 105. Finding Include: 1. During a medication administration observation on 01/20/18 at 8:10 A.M., Licensed Practical Nurse (LPN) #302 administered medications to Resident #9. The nurse prepared medications and placed them in a medication cup and walked down to resident's room. Resident #9 was receiving care and the door was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to revise Resident # 73 and Resident #24 Care Plan. This affected two residents (Resident #73 and #24) of 21 residents reviewed for Care Plans. The facility census was 105. Finding Include: 1. Record review revealed Resident #73 was admitted on [DATE]. Diagnosis included diabetes, bilateral below the knee amputee, major depressive disorder, muscle weakness and hypertension. Quarterly Minimum Data Set 3.0 (MDS) assessment, dated 11/18/18, documented Resident #73 was cognitively intact, needed extensive assist with bed mobility and toilet use and required total dependence with transfers, was frequent incontinent of urine and always incontinent of stool. Review of Physician order dated 11/18/18 documented to use a Hoyer lift, an assisted device used to lift patients, for all transfers. Observation on 01/15/16 at 8:32 A.M. of two State Tested Nurse Aide(STNA) #350 and # 351 transferring Resident #73 from the bed to his wheelchair not using a Hoyer…

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 accurately document Resident #48 blood sugars in the Medication Administration Record. This affected one Resident (#48) of 21 Residents reviewed for medications. The facility census was 105. Findings include: Record review revealed Resident #48 was admitted on [DATE]. Diagnosis included diabetes, muscle weakness, Parkinson's, difficulty swallowing and hypertension. Quarterly Minimum Data Set 3.0 (MDS) assessment, dated 11/17/18, documented Resident #48 was cognitively intact, needed limited assistance with bed mobility, transferring and the use of toilet. Physician order dated 03/14/17 documented to obtain blood sugars at 8:00 A.M. and 9:00 P.M. and administer insulin according to the sliding scale. Resident may take check own blood sugar. Review of Medication Administration Record (MAR) for January 2019 revealed all blood sugars were documented accurately. December 2018 revealed no documentation of blood sugars at 8:00 A.M. on the 24th, 30th and 31st…

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.