Wickliffe Country Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the interdisciplinary team addressed all of Resident #99's discharge needs to ensure a safe discharge. This affected one resident (Resident #99) of one resident reviewed for discharge.Findings include:Resident #99's closed medical record revealed the resident was admitted to the facility on [DATE] due to a fall at home and her husband being admitted to the hospital. Resident #99 diagnosis consists of fracture of upper end of left humerus, emphysema, anxiety, hypertension, alcohol abuse, history of falling, and need for assistance with personal care. Resident #99 admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of six out of 15 which confirmed severe cognitive impairment. Resident #99 ambulated independently, but can be unsteady at times, and needed assistance toileting and getting in and out of bed. Resident #99 was an elopement risk, and a wander guard was implemented on [DATE]…

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

Based on observation, interview, record review and review of the facility policy the facility failed to ensure activity outings outside of the facility were provided for the residents. This affected one resident (Resident #95) of two residents reviewed for activities. The facility census was 128. Findings include: Review of the Activity Calendar dated February 2026 through June 2026 did not reveal evidence outside outings were scheduled for the facility. The January 2026 Activity Calendar for the secured unit was provided and had an outing scheduled for the local library on 01/06/26 at 2:00 P.M. but the January 2026 Activity Calendar was not provided for the entire facility. Interview on 06/24/26 at 3:23 P.M. with Activity Director (AD) #619 revealed she and Activity Assistant (AA) #276 provided activities for the residents. AD #619 revealed she started working at the facility on 03/17/26 and provided a variety of activities for the residents. AD #619 revealed she did not drive the bus for outings outside the facility, and there was a problem getting the bus for outside activities…

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 #22's blood glucose levels will properly monitored before administration of insulin in accordance with physician orders and care planned interventions, and failed to ensure Resident #113's cardiac medication was ordered and administered properly. This affected two residents (Resident #22 and Resident #113) out of five residents reviewed for quality of care. Findings include:1. Review of the medical record revealed Resident #22 was admitted on [DATE] with relevant diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar), chronic kidney disease, major depressive disorder, and hyperlipidemia (high fat in the blood). Review of the care plan (updated 05/09/24) for Resident #22, revealed a care plan for at risk for hyper/hypoglycemic reactions, abnormal lab values, diabetic ulcers, peripheral vascular disease, related to type 2 diabetes mellitus, chronic kidney disease, and use of antidiabetic medications. Relevant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place at all times. This affected two residents (Resident #20 and Resident #149) of four residents reviewed for pressure ulcers. Findings include:1. Review of the medical record for Resident #149 admitted on [DATE] with diagnosis of acquired absence of left leg below the knee, surgical amputation aftercare, posthemorrhagic anemia, severe protein calorie malnutrition, type two diabetes, hypertension, and pulmonary vascular disease. Resident #149 had a surgical wound to left leg and a pressure ulcer on his coccyx. Resident #149 short and long-term memory were intact and could make informed decisions and could make needs known. Review of the physician orders for Resident #149 dated 06/11/26 revealed a skin prevention order for a low air loss mattress to the bed and to check function every shift.Observation on 06/22/26 at 12:11 P.M. of Resident #149's room revealed a semiprivate room with a navy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Occupational Therapy Evaluation and Plan of Treatment, and review of the facility policy the facility failed to ensure Resident #113's care planned fall preventive interventions. This affected one resident (Resident #113) out of three residents reviewed for falls. The facility census was 128. Findings include:Review of Resident #113's medical record revealed an admission date of 01/10/26 and diagnoses included emphysema, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease.Review of Resident #113's care plan dated 01/10/26 and revised on 01/12/26 included Resident #113 was a fall risk characterized by impaired mobility. Resident #113 would have no fall related injuries that required hospitalization through the review date. Interventions included bed in low position while in bed; encourage Resident #113 to call for assistance. Review of Resident #113's Occupational Therapy Evaluation and Plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #113 had a comprehensive evaluation and care planned interventions for a significant childhood trauma. This affected one resident (Resident #113) out of three residents reviewed for trauma. The facility census was 128. Findings include: Review of Resident #113's medical record revealed an admission date of 01/10/26 and diagnoses included emphysema, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease.Review of Resident #113's Social Service admission assessment dated [DATE] included Resident #113 responded yes to the question have you experienced or witnessed a traumatic event in your life. Resident #113 described the trauma as a car accident in my life, and he would like to speak with a mental health professional. The assessment stated Resident #113's care plan reflected his needs and wishes related to trauma.Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure effective care planned interventions were implemented to promote Resident #161's highest practicable physical, mental, and psychosocial well-being. This affected one (Resident #161) of one residents reviewed for behavioral health. The facility census was 128. Review of the medical record revealed Resident #161 was admitted to the facility on [DATE] from an acute care hospital stay. The resident had relevant diagnoses of adult failure to thrive, focal traumatic brain injury (TBI), restlessness and agitation, hypertension (high blood pressure), and anemia.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03 (severe cognitive impairment) and disorganized thinking. The resident was independent for all activities of daily living (ADL) apart from set up assistance for oral hygiene and putting on and taking off footwear. The resident 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 properly identify Resident #106's food allergies to ensure interventions were in place to provide the correct diet. This affected one resident (Resident #160) out of six residents reviewed for food. Findings include:Review of medical record revealed Resident #160 was admitted to the facility on [DATE]. Medical diagnosis included cognitive communication deficit, traumatic brain injury, post traumatic stress disorder, attention deficit hyperactivity disorder, autistic disorder, asthma. Allergies included Amoxicillin, diphenhydramine, fluoxetine, hazelnut, ketorolac, morphine, peanut oil, penicillin, peanuts, chocolate hazelnut flavor.Review of Resident #160's physician orders, dated 06/23/26, revealed Resident #160 was to receive a regular diet, regular diet texture thin liquid consistency.Review of Resident #160's physician orders, dated 06/24/26, revealed Resident #160 was to receive epinephrine zero point three milligrams solution auto…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy revealed the facility failed to ensure sufficient staff were available to timely serve meal trays for the 18 residents residing on the A unit and failed to provide timely incontinence care for three residents. This affected three (#80, #109, and #111) of three residents reviewed for incontinence care also residing on the A unit. This had the potential to affect all 18 residents (#80, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112, #113, #114, and #115) residing on the A Unit. The facility census was 114.Findings include: 1. Record review for Resident #80 revealed an admission date of 08/23/23. Diagnoses included multiple sclerosis, spinal stenosis, and muscle weakness. Review of the Annual Minimum Data Set (MDS) dated [DATE] for Resident #80 revealed Resident #80 had a Brief Interview of Mental Status (BIMS) score of 12 (moderately cognitively impaired). Resident #80 required set up or clean up…

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 facility staff and pharmacy staff interview, medical record review, review of Self- Reported Incident (SRI) #264042 and facility policy review the facility failed to thoroughly investigate a missing controlled medication for one resident. This affected one (#181) of one resident reviewed for misappropriation of medications. The facility census was 114. Findings include: Record review for Resident #181 revealed an admission date of 06/04/25 and a discharge date of 09/03/25. Diagnoses included bipolar disorder and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181 was cognitively intact. Resident #181 had little interest or pleasure in doing things and was feeling down, depressed or hopeless. Resident #181 used a wheelchair for mobility and was independent for eating and personal hygiene. Resident #181 had non-traumatic brain dysfunction, bipolar disorder and schizophrenia. Review of the physician order for Resident #181 dated 07/19/25 revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy revealed the facility failed to assure trach supplies were available and care and treatment was completed. This affected one (#52) of one resident reviewed for trach supplies and treatment. The facility census was 114.Findings include: Record review for Resident #52 revealed an admission date of 03/06/24. Diagnoses included encounter for attention to tracheostomy (a direct opening or stoma through the neck into the windpipe (trachea) allowing a tube to be inserted to provide an airway), dysphagia, weakness, unspecified psychosis, obsessive compulsive disorder, post-traumatic stress disorder and obstructive sleep apnea. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired. Resident #52 had no rejection of care and required set up or clean up assistants with eating and oral hygiene. Resident #52 had a tracheostomy and received tracheostomy care. Review of the care plan…

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

Based on observation, interview, record review and facility policy review, the facility failed to follow the renal diet menu. This affected two residents (#115 and #129) of three residents reviewed for nutrition, and affected ten additional residents (#3, #16, #22, #42, #46, #56, #64, #94, #99 and #105) who received a renal diet. The facility census was 129. Findings include: Review of the medical record for Resident #115 revealed an admission date of 11/18/24. Diagnoses included end stage renal disease, peripheral vascular disease, and non-pressure chronic ulcers to the right and left lower leg. Physician orders effective January 2025 specified a renal diet with regular texture and thin consistency. Review of the medical record for Resident #129 revealed an admission date of 06/17/20. Diagnoses included severe chronic kidney disease, adult failure to thrive and severe protein calorie malnutrition. Physician orders effective January 2025 specified a renal diet, mechanical soft with pureed fruit texture and thin consistency with large portions. Interview on 01/29/25 at 7:55 A.M. with…

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

Based on observations and interview the facility failed to maintain a sanitary kitchen. This had the potential to affect all residents residing in the facility except for three residents (#9, #93, and #123) who did not receive nutrition by mouth. The census was 126. Findings include: Observations on 09/23/24 at 8:35 A.M. of the kitchen revealed two garbage cans lids covered with dust and food debris, a paper inspection tag for the ancillary alarm located on the wall was located on the floor by doorway, the tag was covered with brownish debris and difficult to read inspection dates. The entire floor of kitchen was covered with food debris and miscellaneous grime, the bottom of a shelving unit holding clean sheet pans was covered with dust and miscellaneous food debris. Observations on the walk-in refrigerator revealed a bag of green/brownish lettuce on the self, the bag was not dated. There was a plastic container storing food scoops located under the serving table that had miscellaneous food debris surrounding the scoops. The outside including the handle of the microwave was covered…

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

Based on observations and interviews the facility failed to maintain a sanitary environment surrounding the dumpster area. This had to potential to affect all 126 residents residing in the facility. Findings include: Observations on 09/23/24 at 8:54 A.M. revealed plastic garbage bags filled with food and other miscellaneous items, soiled adult briefs, latex gloves, plastic forks/spoons, Styrofoam cups surrounding three dumpsters located in the parking lot. Interview during the observations, Food Service Director #166 verified the observations stating the garbage would be cleaned up immediately. No facility policy was provided related to maintaining a clean and sanitary area surrounding the dumpsters.

Based on interview, record review and review of facility policy revealed the facility did not ensure Resident #32's advanced directives were accurate per the physician orders on her electronic medical record. This affected one resident (#32) out of 43 residents reviewed for advanced directives. The facility census was 126. Findings included: Review of the medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and hypertension. Review of the Do Not Resuscitate (DNR) Comfort Care form dated 08/02/23 and completed by Nurse Practitioner (NP) #500 revealed Resident #32 was to be a DNR Comfort Care- Arrest. Review of the care plan dated 08/24/23 revealed Resident #32 and/ or family had chosen to have an advanced directive: DNR Comfort Care- Arrest. Interventions included the facility would review code status when significant change in condition occurred, monitor for appropriateness of a hospice consult, and review advance directive status with plan of care meetings. Review of September…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policies the facility failed to ensure the resident, physician, legal guardian and/ or responsible party was notified regarding significant weight changes. This affected two residents (#16 and #32) out of seven residents reviewed for proper notifications of significant weight change. The facility census was 126. Findings included: 1. Review of the medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and dysphagia. She had a legal guardian. There was no documentation in the medical record regarding the physician, and legal guardian being notified of Resident #32's significant weight loss of 17.1 percent from 02/01/24 to 05/08/24. Review of the weight record for Resident #32 from 01/08/24 to 09/24/24 revealed she had the following weights: 01/08/24 her weight was 197.6 pounds, 01/30/24 her weight was 202.3 pounds, 02/01/24 her weight was 193 pounds, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident received bathing as planned and/or as requested. This affected one resident (#180) of five residents reviewed for showers. The facility census was 126. Findings include: Review of the medical record for Resident #180 revealed an admission date of 09/04/24. Diagnoses included but were not limited to type II diabetes mellitus, stage III chronic kidney disease and history of transient ischemic attacks. Review of the 09/04/24 admission Minimum Data Set (MDS) 3.0 for Resident #180 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #180 required set up assistance for bathing. Review of the care plan dated 09/06/24 for Resident #180 revealed under preferences, preferred showers. Review of the facility shower schedule revealed Resident #180 was to receive showers on Wednesdays and Saturdays during the 3:00 P.M. to 11:00 P.M. 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.

Based on record review, observation, and interview the facility failed to provide assistance to maintain personal hygiene. This affected one (Resident #69) of five residents reviewed for activities of daily living. The census was 126 Findings include: Review of medical record for Resident #69 revealed an admission date of 11/04/21. Diagnoses included depression, unspecified and type two diabetes. The resident had impaired cognition. Review of the annual Minimum Data Set (MDS) assessment, dated 09/06/24, revealed Resident #69 had intact cognition. The resident required maximum assistance for personal hygiene. Review of the plan of care dated 09/10/24 revealed Resident #69 had a activity of daily living (ADL) self-care performance deficit related to impaired mobility and generalized weakness. Interventions included for staff to provide total oral care, provide extensive assistance with personal hygiene; and encourage to start task and finish if the resident becomes tired or unable to complete. Observation on 09/23/24 at 10:22 A.M., Resident #69 was observed to have facial hair…

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, record review, and review of facility policy revealed the facility failed to implement fall interventions as identified in the resident's plan of care. This affected one resident (#32) of four residents reviewed for falls and/ or accidents. The facility census was 126. Findings included: Review of medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and hypertension. Review of care plan dated 07/08/24 revealed Resident #32 was at risk for falls due to impaired mobility, generalized weakness, Schizophrenia, and neuropathy. Interventions included assist with transfers, locomotion and mobility, grab bar to bed, commonly used items within easy reach, and protective floor mat next to bed that was added on 08/29/24. Review of the care plan dated 07/08/24 revealed Resident #32 had a self-care performance deficit related to impaired mobility, generalized weakness, and neuropathy.…

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, record review, and review of facility policies the facility did not ensure weights were obtained and monitored timely. This affected two residents (#16 and #32) of seven residents reviewed for nutrition. The facility census was 126. Findings included: 1. Review of medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included Schizophrenia, diabetes, moderate protein-calorie malnutrition, and dysphagia. She had a legal guardian. There was no documentation in the medical record regarding the physician, and legal guardian was notified of Resident #32's significant weight loss of 17.1 percent from 02/01/24 to 05/08/24. Review of weight record for Resident #32 from 01/08/24 to 09/24/24 revealed she had the following weights: 01/08/24 her weight was 197.6 pounds, 01/30/24 her weight was 202.3 pounds, 02/01/24 her weight was 193 pounds, and 05/08/24 her weight was 160 pounds which indicated a 17.1 percent significant weight loss. The weight record also…

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, record review, and review of facility policy the facility failed to ensure Resident #108's enteral tube feeding (a method of providing nutrition to patients who are unable to eat or drink safely by mouth) was infusing at the correct rate per physician order. This affected one resident (#108) of two residents reviewed for tube feeding. Findings included: Review of the medical record for Resident #108 revealed an admission date of 12/08/23 and diagnoses included heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition. Review of care plan dated 12/08/23 revealed Resident #108 had a feeding tube to assist in maintaining or improving nutritional status related to cerebral infarction, and difficulty swallowing. Interventions included tube feeding per dietary recommendation and physician order, check placement of feeding tube, keep head of bed elevated and monitor for complications. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #108 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.

Based on interview, observation, policy review and review of the medical record revealed the facility failed to ensure enteral feedings were labeled and dated appropriately. This affected one resident (#93) of two residents reviewed for enteral feedings. The facility census was 126. Findings include: Review of the medical record for Resident #93 revealed an admission date of 10/06/22. Diagnoses included but were not limited to encephalopathy, gastrostomy, dysphagia, and history of transient ischemia attack (TIAs). Review of the 09/02/24 annual Minimum Data Set (MDS) 3.0 for Resident #93 revealed a Brief Interview for Mental Status (BIMS) revealed severe cognitive impairment. Resident #93 and was dependent for all Activities of daily living (ADLs) and received a tube feeding. Review of physician orders dated 11/10/23 for Resident #93 revealed an order to change enteral feeding bag and syringe every night shift for routine care and label with date. Review of physician orders dated 09/01/24 for Resident #93 revealed an order for Isosource 1.5 calorie enteral feed at 50 milliliters (mL)…

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, record review and review of facility policy revealed the facility failed to ensure enhanced barrier precautions were utilized for a resident during high contact resident care. This affected one resident (#108) of two residents observed for enhanced barrier precautions. Findings included: Review of the medical record for Resident #108 revealed an admission date of 12/08/23 and diagnoses included heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition. Review of care plan dated 12/08/23 revealed Resident #108 had a feeding tube to assist in maintaining or improving nutritional status related to cerebral infarction, and difficulty swallowing. Interventions included enhanced barrier precautions with high contact care including using a gown and gloves for dressing change and tube feeding care, check placement of feeding tube, keep head of bed elevated and monitor for complications. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, menu spreadsheet review, and policy review the facility failed to serve palatable meals at appetizing temperatures. This affected 117 residents receiving meals from the kitchen as two residents (#67 and #108) were ordered nothing-by-mouth (NPO). The facility census was 119. Findings include: Review of a menu for week two, Tuesday corresponding to 03/26/24 revealed the following for the lunch meal: barbeque pork shoulder, tater tots, coleslaw, biscuit, and a spiced pear bar. Interview on 03/25/24 at 10:20 A.M. with Resident #116 revealed food was terrible, did not taste good, and was often cold. Interview on 03/25/24 at 10:32 A.M. with Resident #68 revealed the food sometimes was not warm. Interview on 03/25/24 at 10:42 A.M. with Resident #5 revealed the food was sometimes cold. Observation of the lunch meal on 03/26/24 starting at 11:30 A.M. revealed [NAME] #414 took temperatures of the foods to be served with the facility's self-calibrating electronic thermometer as follows:…

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 have sufficient staff to provide the necessary care and services including restorative nursing, getting assistance to bed per preference and timely manner, timely incontinence care, showers per schedule and preference, changing of clothing, and meeting the minimum daily staffing requirement of 2.50 hours per resident. This had the potential to affect all 137 residents residing in the facility. Findings include: 1. Review of the staffing tool with Scheduler/ State Tested Nursing Assistant (STNA) #725 on 09/22/22 at 11:57 A.M. revealed the facility did not meet the minimum daily staffing requirement of 2.50. On 09/18/22 the facility had 2.42 hours of direct care staff per resident. Interview on 09/22/22 at 11:57 A.M. with Scheduler/ STNA #725 verified on 09/18/22 there was 2.42 hours of direct care staff per resident. She revealed there were several call offs on 09/18/22, and they were unable to cover all the call offs to meet the daily…

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 interviews, the facility failed to serve hot and palatable foods. This had the potential to affect all 132 residents receiving food from the facility kitchen. Five (Resident's #25, #48, #38, #50, and #127) did not receive food from the facility. The facility census was 137. Findings include: Interview with Resident #67 on 09/19/22 at 12:57 P.M. revealed the food was usually not hot. Sometimes the facility used plates and sometimes the facility used Styrofoam. Interview with Resident #441 on 09/19/22 at 12:08 P.M. revealed the food was often cold, and there was not anything I would eat at home. Interview with Resident #71 on 09/19/22 at 12:43 P.M. revealed the food was cold sometimes. Interview with Resident #1 on 09/19/22 at 1:24 P.M. revealed the food was often cold. Interview with Resident #72 on 09/19/22 at 3:11 P.M. revealed the food was cold. Interview with Resident #27 on 09/19/22 at 4:51 P.M. revealed the food was terrible and never hot when it arrives to the 300-hall. Interview with Resident #12 on 09/20/22 at 8:42 A.M. revealed the food was bad,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to provide consistent and timely assistance with activities of daily living (ADL) for incontinence care and showers. This affected four (Resident's #17, #116, #441 and #453) of eight residents reviewed for ADL. The facility census was 137. Finding included: 1. Review of the medical record for Resident #116 revealed an admission date of 10/23/17 with diagnoses including cervical disc disorder, polyneuropathy, contracture right and left knee, and contractures of the right and left hip. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The resident required the extensive assistance of two staff for bed mobility and dressing. The resident was totally dependent on two staff for transfers, toilet use, and personal hygiene and required the extensive assistance of one staff for locomotion and eating. Interview on 09/20/22 at 8:51 A.M. Resident #116 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Centers for Disease Prevention and Control (CDC) guidance, and review of the facility policy the facility failed to ensure two (Resident's #1 and #450) were placed on contact precautions timely. The facility failed to ensure appropriate hand hygiene during and after care the of one (Resident #1) who was on contact precautions. The facility failed to ensure tuberculin screening tests were administered and read within the required time frame for two (Resident's #3 and #453). This affected two (Resident's #1 and #450) of three residents reviewed for transmission-based precautions, one (Resident #1) of three residents reviewed for hand hygiene, and two (Resident's #3 and #453) of five reviewed for tuberculin screening. The facility census was 137. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 05/24/22 with diagnoses including encounter for surgical aftercare following surgery on the digestive system, unspecified…

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, record review, and facility policy review the facility failed to ensure water temperatures were maintained in a safe manner at or below 120 degrees Fahrenheit (F). This affected eight residents (Resident's #12, #15, #20, #45, #95 #109, #116 and #136) and had the potential to affect 101 residents who resided on the 100, 200, 300, and 500 halls (Resident's #1, #2, #3, #4, #5, #6, #7, #9 #12, #13, #15, #16, #17, #20, #21, #25, #27, #30, #31, #33, #35, #37, #38 #41, #43, #44, #45 #47, #48, #49, #51, #52, #54, #55, #57, #59, #60, #61, #62, #63, #65, #66, #67, #68, #89, #70 #71, #72, #73, #74, #75, #77, #79, #80, #82, #86, #87, #93, #95, #96, #97, #99, #102, #104, #106, #108, #109, #111, #114, #116, #117, #118, #119, #121, #123, #125, #127, #130, #131, #133, #134, #135, #136, #139, #140, #391, #392, #442, #443, #444, #445, #446, #447, #448, #449, #450, #451, #452, #453, #454 and #455) reviewed for physical environment. The facility census was 137. Findings included: Review of the facility form labeled Logbook Documentation: Water Temperature, dated from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure neglect did not occur. This affected two (Resident's #452 and #453) of three residents reviewed for neglect. The facility census was 137. Findings include: 1. Review of Resident #453's medical record revealed an admission date of 09/06/22 with diagnoses including cellulitis of the right and left lower limbs, heart failure, type two diabetes mellitus with diabetic neuropathy, and morbid obesity. Review of Resident #453's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #453 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #453 was always incontinent of urine and frequently incontinent of bowel. Review of Resident #453's care plan dated 09/07/22 included Resident #453 was a fall risk characterized by impaired balance, impaired mobility, incontinence, and cellulitis to lower extremities. The goal was to prevent, minimize fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to implement a care plan intervention after a fall for Resident #122. This affected one (Resident #122) of two Resident #62 and Resident #122) reviewed for accuracy of care plan fall interventions. The facility census was 137. Findings include: Review of the medical record for Resident #122 revealed an admission date of 09/05/18 with diagnoses including diabetes, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and history of falling. Review of the care plan dated 11/3/21 revealed Resident #122 was a fall risk related to impaired mobility, unstable health conditions, unsteady gait, weakness from chronic obstructive pulmonary disease, and history of falls. Interventions included analyze previous resident falls to determine whether pattern, bariatric bed, bed in low position, and reinforce need to call for assistance. The care plan revealed on 08/10/22 the facility implemented an intervention 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 interview, observation, record review, and facility policy review the facility did not ensure Resident's #10 and #116 received their restorative programs per recommendation. This affected two (Resident's #10 and #116) of two (Resident's #10, and #116) reviewed for restorative nursing programs. This had the potential to affect 38 (Resident's #5, #10, #12, #14, #15, #16, #22, #23, #25, #28, #32, #35, #39, #40, #42, #43, #45, #51, #52, #53, #56, #59, #60, #64, #65, #70, #80, #87, #89, #99, #104, #106, #112, #116, #117, #121, #122, and #126) who received a restorative nursing programs. The facility census was 137. Findings included: 1. Review of the medical record for Resident #10 revealed an admission date of 11/23/20 with diagnoses including chronic kidney disease, diabetes, dementia, asthma, and major depression. Review of the care plan dated 02/12/21 revealed Resident #10 had a restorative nursing program due to impaired physical mobility in locomotion related to activity intolerance and weakness.…

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 #45 had orders in place to receive appropriate indwelling catheter care. This affected one (Resident #45) of three residents reviewed for indwelling catheter care orders. The facility census was 137. Findings include: Review of the medical record for Resident #45 revealed an admission date of 11/04/21 wit diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dementia, benign prostatic hyperplasia, and neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS revealed Resident #45 had an indwelling urinary catheter. Review of the September 2022 physician orders for Resident #45 revealed there were no active orders for Resident #45's indwelling catheter care. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure two (Resident's #136 and #450) were administered oxygen as ordered by the physician. This affected two (Resident's #136 and #450) of seven residents reviewed for oxygen administration. The facility census was 137. Findings include: 1. Review of Resident #136's medical record revealed an admission date of 08/30/22 with diagnoses including acute respiratory failure with hypoxia, malignant neoplasm of ascending colon, and end stage renal disease. Review of Resident #136's oxygen saturations summary in the medical record from 09/05/22 through 09/19/22 revealed Resident #136 had oxygen via nasal cannula, and her oxygen saturations ranged from 95 to 100 percent. Review of Resident #136's physician orders from 09/05/22 through 09/19/22 did not reveal orders for oxygen administration. Review of Resident #136's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #136 was cognitively intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to complete dialysis assessments before and after dialysis and send a dialysis communication form to dialysis. This affected one (Resident #93) of one resident reviewed for dialysis. This had the potential to affect 17 additional residents (Resident #2, #6, #26, #31, #35, #54, #74, #82, #84, #87, #111, #119, #133, #134, #139, #443, and #446) who received dialysis. The facility census was 137. Findings include: Review of the medical record for Resident #93 revealed an admission date of 08/05/22 with diagnoses including end stage renal failure, dependence on renal dialysis, spinal stenosis, major depression, and muscle weakness. Review of the physician orders for August 2022 and September 2022 revealed Resident #93 received dialysis three times a week on Monday, Wednesday, and Friday in house, and had a physician order dated 08/10/22 to complete and lock dialysis assessment and dialysis communication forms before and after 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 observation, interview, record review, and review of facility training the facility failed to ensure appropriate supervision for one resident with dementia. This affected one (Resident #455) of three residents reviewed for supervision. The facility census was 137. Findings include: Review of Resident #455's medical record revealed an admission date of 09/14/22 with diagnoses including Alzheimer's disease with late onset, dementia, and delusional disorders. Review of Resident #455's admission assessment dated [DATE] included Resident #455 had cognitive impairment with poor decision-making skills. The resident displayed the following behaviors: easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive, and resistant to care. Resident #455 verbally expressed a desire to go home. Resident #455 ambulated without problem and with devices 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.