Dixon Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, observation and facility policy review, the facility failed to ensure Resident #3 was free from misappropriation. This affected one (Resident #3) of three records reviewed. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact.Review of census revealed Resident #3 was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Ohio Gateway system (online system for reporting abuse) and facility policy review, the facility failed timely to report allegation of misappropriation to the state agency. This affected one (Resident #3) of three residents reviewed. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact.Review of census…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, observation and facility policy review the facility failed to investigate allegation of misappropriation. This affected one (Resident #3) of three residents reviewed.Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition intact.Review of census revealed the resident was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2 on Unit…

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 work order, interview, observation and facility policy review, the facility failed to ensure bilateral enabler bars were in-place per orders to prevent Resident #3 from falling out of bed twice. This affected one (Resident #3) of three records reviewed for accidents. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left bronchus or lung, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage two chronic kidney disease. The resident was under hospice services.Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognition…

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 policy review the facility failed to ensure medications were ordered timely and available for residents. This affected one resident (Resident #7) of four residents reviewed for pharmacy services. Findings include:Record review revealed Resident #7 admitted to the facility 10/10/19 with diagnoses including traumatic brain injury with loss of consciousness, insomnia, neuropathy, quadriplegia, muscle spasms, neuromuscular bladder dysfunction, and hyperkalemia.Record review of Resident #7 quarterly minimum data set (MDS) assessment completed 08/14/25 revealed the resident's cognition was intact, had no observed or exhibited behaviors, was dependent for toileting, showering, bathing, lower body dressing, and personal hygiene, and was dependent or required maximum assistance for mobility. MDS revealed Resident #7 received an opioid medication. Review of quarterly care plan initiated on 11/09/21 and revised on 08/25/25 revealed Resident #7 had complaints of chronic pain related 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 review of pest invoices, review of concerns submitted to the state survey agency complaint intake unit, interviews, observation, and review of facility policy revealed the facility failed to ensure an effective pest control program was maintained. This had the potential to affect all 63 residents residing in the facility. Findings include:1 a. Review of concerns submitted to the state survey agency complaint intake unit dated 06/13/25 and 07/10/25 revealed a concern with cockroaches in the kitchen. Review of the pest control invoice dated 06/10/25 revealed the building was inspected for services including all interior areas for possible pest entry ways and activity. All glue boards were replaced as needed. Open area of concern was noted in the kitchen. The wall covering was loose/peeling. Wall tile was cracked and there were gaps between baseboards and wall. These areas need repaired or replaced to help prevent pest entry and harbor sites. The kitchen door seal was not rodent proof. The seal needed repaired. There were German Cockroaches noted to be found on the devices.…

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, review of funds list, and policy review, the facility failed to ensure residents had access to personal funds after business hours and on weekends. This affected four residents (#4, #22, #30 and #36) of four residents reviewed for personal funds managed by the facility. The facility census was 63.Findings include:Review of the facility funds list dated 07/08/25 revealed Residents #4, #22, #30, and #36 each had a personal funds account with the facility. Observation and interview on 07/08/25 at 7:26 A.M., with HR #153 confirmed she was responsible for dispensing resident funds. The surveyor requested to observe the money box for resident funds. HR #153 confirmed she did not leave a money box for staff after she left Tuesday at 5:00 P.M. The HR reported she leaves the money box on the weekends in the medical room, however, could not recall which staff member she had given to the box to the week prior. HR #153 reported most of the resident know they need to get money out before she leaves at the end of the day. Interview on 07/08/25 at 7:30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of self-reported incidents (SRI), interviews, and policy review, the facility failed to prevent misappropriation of Resident #48's narcotic pain patches. This affected one resident (#48) of three residents reviewed for controlled medications. The facility census was 63. Findings include: Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including hospice services, chronic obstructive pulmonary disease, type two diabetes, absence of eye and above right knee, anxiety, peripheral vascular disease, aphasia, bursitis of right elbow, and heart disease. Review of Resident #48's orders dated 03/31/25 to present revealed Fentanyl (an opioid analgesic) 50 microgram (mcg) patch. Instructions stated to apply one patch topically to the resident's upper torso every 72 hours routinely for pain. Review of Resident #48's admission assessment completed 03/31/25 revealed the resident was not capable of verbalizing pain. The resident was noted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and facility policy review, the facility failed to timely investigate an injury of unknown origin. This affected one resident (#31) of three residents reviewed for abuse. The facility census was 63. Findings include:Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia with other behavioral disturbance, conversion disorder with seizures or convulsions, anxiety, depression, paranoid schizophrenia, and nontraumatic intracerebral hemorrhage. Review of Resident #31's skin assessment dated [DATE] revealed the resident had skin tear on the left elbow measuring 2.0 centimeter (cm) in length by one cm in width by 0.1 cm depth. The diagnoses was fragile skin. Review of Resident #31's order dated 07/02/25 revealed to cleanse the left elbow with normal saline, pat dry, apply xeroform (a non-adherent gauze dressing) and cover with silicone boarder foam dressing. Instructions included to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interviews, the facility failed to ensure that adequate care and treatment was provided for a resident with left arm edema and failed to ensure bruising was assessed and documented. This affected one resident (#31) of three residents reviewed for change in condition. The facility census was 63. Findings include:Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia with other behavioral disturbance, conversion disorder with seizures or convulsions, anxiety, depression, paranoid schizophrenia, and nontraumatic intracerebral hemorrhage. Review of Resident #31's progress notes dated 07/04/25 to 07/06/25 revealed no evidence the resident had left arm edema. Review of Resident #31 progress note dated 07/07/25 at 12:35 P.M., revealed the resident had a telehealth visit completed for concern of a swollen left arm. Nurse Practitioner (NP) #200 ordered a doppler (a non-invasive ultrasound…

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, interview, and policy review the facility failed to ensure residents received effective pain management. This affected three residents (#48, #61, and #65) of three residents reviewed that received pain patches. Findings include:1. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including hospice services, chronic obstructive pulmonary disease, type two diabetes, absence of eye and above right knee, anxiety, peripheral vascular disease, aphasia, bursitis of right elbow, and heart disease. Review of Resident #48's admission assessment completed [DATE] revealed the resident was not capable of verbalizing pain. The resident was displaying non-verbal indicators of pain. The resident was receiving scheduled pain medication. Review of Resident #48's aphasia plan of care dated [DATE] and revised [DATE] revealed the resident had a communication problem. Interventions included observing/document for physical/nonverbal indicators 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 medical record review, interview, and policy review the facility failed to ensure narcotic medication (pain patches) were properly disposed of. This affected two residents (#48 and #65) of three residents reviewed that received narcotic pain patches. The facility census was 63.Findings include:1. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes, absence of eye and above right knee, anxiety, peripheral vascular disease, aphasia, bursitis of right elbow, and heart disease. Review of Resident #48's orders dated [DATE] to [DATE] revealed Fentanyl (narcotic medication) 50 microgram (mcg) patch. Apply one patch topically to upper torso every 72 hours for pain. Review of Resident #48's Fentanyl 50 mcg control drug record dated [DATE] to [DATE] revealed on [DATE], [DATE], [DATE], unknown date (no date documented), [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [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 record review, interview and policy review, the facility failed to notify a family and physician of a resident fall. This affected one resident (#64) of three residents reviewed for falls. Findings include: Review of Resident #64's medical record revealed a 09/25/23 admission with diagnoses including chronic diastolic congestive heart failure, type two diabetes, gastroesophageal reflux, disease, hypertension, hypothyroidism, moderate protein calorie malnutrition, cardiomyopathy, personal history of transient ischemic attacks without residual deficits, depression, dysphasia, neuropathy Non-rheumatic mitral valve stenosis and dementia. Review of a 05/09/25 quarterly minimum data set assessment (MDS) revealed the resident was severely impaired for daily decision-making with hallucinations, verbal behavior symptoms one to three of the look back days. She said no upper or lower body functional impairment. The resident was dependent on staff for oral hygiene, toileting, bathing, and on upper and lower body dressing and personal hygiene. She was dependent on staff for locomotion…

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, hospice communication review, and interview, the facility failed to ensure a resident who was dependent on staff for care received showers per preference. This affected one resident (#64) of three residents reviewed for showers. Findings include: Review of Resident #64's medical record revealed a 09/25/23 admission with diagnoses including chronic diastolic congestive heart failure, type two diabetes, gastroesophageal reflux, disease, hypertension, hypothyroidism, moderate protein calorie malnutrition, cardiomyopathy, personal history of transient ischemic attacks without residual deficits, depression, dysphasia, neuropathy Non-rheumatic mitral valve stenosis and dementia. The resident had a 04/15/24 Self Care Performance plan of care related to cognition and functional deficits. The resident was totally dependent on staff for bathing. Review of a 05/09/25 quarterly minimum data set assessment (MDS) revealed the resident was severely impaired for daily decision-making with hallucinations,…

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, Sheriff report review, interview, and policy review, the facility failed to ensure resident needs were met related to a fall and supervision was provided related to resident safety. This affected two residents(#42 and #64) of seven residents reviewed. Findings include: 1. Review of Resident #64's medical record revealed a 09/25/23 admission with diagnoses including chronic diastolic congestive heart failure, type two diabetes, gastroesophageal reflux, disease, hypertension, hypothyroidism, moderate protein calorie malnutrition, cardiomyopathy, personal history of transient ischemic attacks without residual deficits, depression, dysphasia, neuropathy, non-rheumatic mitral valve stenosis and dementia. Review of a 05/09/25 quarterly minimum data set assessment (MDS) revealed the resident was severely impaired for daily decision-making with hallucinations, verbal behavior symptoms one to three of the look back days. She had no upper or lower body functional impairment. 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 record review, interview, and policy review the facility failed to provide evidence the physician conducted in-person examination of all residents. This affected one resident (#51) of three residents reviewed for physician documentation. The facility census was 62. Findings include: Record review of Resident #51 revealed an admission date of 10/04/24. Diagnoses include Type 2 Diabetes Mellitus with diabetic neuropathy (nerve pain), Asthma, Morbid Obesity, Bipolar Disorder, Atrial Fibrillation (an abnormal hearth rhythm), Acute Respiratory Failure, Hypertension (high blood pressure), and Hyperlipidemia (high levels of fat in the blood). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was admitted to the facility from a short-term general hospital. Review of the progress notes since admission revealed no notes in the electronic medical record written by the Medical Director #1 who was the attending physician for Resident #51. Interview with the director of nurse (DON) #1…

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, policy review, and staff interview, the facility failed to maintain accurate resident medical records. This affected two residents (#42 and #64) of seven residents reviewed. Findings include: 1. Review of Resident #64's medical record revealed a 09/25/23 admission with diagnoses including chronic diastolic congestive heart failure, type two diabetes, gastroesophageal reflux, disease, hypertension, hypothyroidism, moderate protein calorie malnutrition, cardiomyopathy, personal history of transient ischemic attacks without residual deficits, depression, dysphasia, neuropathy Non-rheumatic mitral valve stenosis and dementia. Interview on 05/22/25 at 5:31 P.M. with Resident #64's daughter revealed she had an electronic monitoring device with a camera in her mother's room. She stated she saw her mother on the floor on camera footage and did not receive a call about a fall. She showed the footage to the Director of Nursing who said she did not know about the fall. Interview on 05/22/25 at 5:57…

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, policy review, and interview, the facility failed to ensure contact isolation precautions were implemented for a resident with a multi drug resistant organism with drainage that was not contained. This affected one resident (#63) of seven residents reviewed for infection control practices. Findings include: Review of the closed medical record for Resident #63 revealed an admission date of 03/28/25 with diagnoses of cellulitis, morbid severe obesity (410 pounds (lbs) on 04/21/25), cor pulmonale, congestive heart failure, hypertension, respiratory failure, acute and chronic renal failure, adult failure to thrive, psychoactive substance abuse, Stage 3 chronic kidney disease, chronic venous insufficiency, iron deficiency anemia, and lymphedema. Review of a Medical Director order dated 03/29/25 revealed Resident #63 was admitted to the facility for skilled level of care with therapy and/or nursing services. He was receiving oral and intravenous antibiotics for cellulitis to right posterior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of facility Self Reported Incidents, review of facility investigation, interview with staff, interview with residents, and review of faciliy policy and procedure, the facility failed to report an allegation of staff to resident sexual abuse to the State agency. This affected one resident (Resident #71) out of five residents reviewed for abuse and neglect. Finding included: Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, diabetes, neuropathy, hepatitis C, hypertension, anxiety disorder, major depressive disorder, complete traumatic amputation between the elbow and wrist of the left arm and phantom limb syndrome. Resident #71 was his own responsible party. Review of the plan of care dated 06/14/24 revealed no documentation of inappropriate sexual behaviors being exhibited by the resident. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, interview with staff, and review of facility policy and procedure, the facility failed to follow physician's orders to monitor the dialysis fistula bruit and thrill for Resident #72. This affected one resident (Resident #72) of three reviewed for dialysis. Findings included: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart, end stage renal disease with dialysis, diabetes, hypothyroidism, dementia, major depressive disorder, hydronephrosis, benign prostatic hyperplasia, and mood disorder. He was discharged to the hospital on [DATE] where he later expired. Review of the physician order dated [DATE] revealed Resident #72 had an order to check his dialysis graft site for bruit and thrill every shift. Review of the hemodialysis care plan dated [DATE] revealed Resident #72 was receiving hemodialysis therapy related to renal failure and he had an AV fistula to the left upper extremity. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, interview with staff, and review of manufacture guidelines, the facility failed to maintain a medication error rate below five percent (%). There were two medication errors out of 29 opportunities for error, equaling a medication error rate of 6.9 %. This affected two residents (#59 and #66) of five residents (Resident #6, #48, #52, #59 and #66) observed for medication administration. Findings included: 1. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), dyspnea, and schizophrenia. Review of the March 2025 physician's orders revealed Resident #66 had an order dated 09/21/23 for Fluticasone propionate and salmeterol inhalation powder 250/50 micrograms (mcg) with instructions to administer one puff twice daily for COPD, and swish and spit after usage. Observation of medication administration on 03/11/25 at 7:30 A.M. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure isolation laundry was handled and sanitized properly, failed to ensure infection control was maintained and enhanced barrier precautions (EBP) were implemented during tracheostomy care for Resident #53 and during medications administration for Resident #37. This had the potential to affect all residents residing in the facility who used the facility laundry, affected one resident (Resident #53) of two reviewed for tracheostomy care and affected one resident (Resident #37) of one observed for tube feeding medication administration. The facility census was 74. Findings include: 1. Review of the infection control surveillance logs revealed the last resident on isolation was on 08/20/24 for methicillin-resistant staphylococcus aureus and the last clostridium difficile was on 06/14/24. On 12/19/24 at 9:57 A.M. an interview with Laundry Staff #302 revealed she would go out to the units, get the linen…

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 policy review the facility failed to maintain water temperatures in a manner to ensure residents were provided sufficient and comfortable hot water for use with bathing/personal hygiene. This affected four residents (#32, #42, #56, and #63) of fifteen residents interviewed. Findings included: Interview on 12/18/24 at 2:53 P.M., with Resident #32 and Resident #42 revealed the hot water in their sink was hit and miss especially the last two weeks. The residents reported the water had been so cold staff has had to go to the shower room to obtain hot water to ensure they received warm water to take their bed baths. Interview on 12/18/24 at 3:53 P.M., with Maintenance Director (MD) revealed he had started two weeks ago, and hot water temperatures had been an issue since he started. The MD reported one of the three hot water tanks was not working because it needed a new thermostat control unit. The MD reported he didn't know which hot water tank serviced which part of the building.…

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 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included hypokalemia, bulbous ureteral stricture hematuria, benign prostatic hyperplasia, retention of urine, diabetes, hyperlipidemias, respiratory failure, atrial fibrillation, osteoarthritis, major depressive disorder, and dementia. Review of weights in Point Click Care for Resident #45 revealed on 07/07/24 he weighed 172.4 and on 10/09/24 he weighed 154.6 for a 10.3 percent weight loss. Review of the nutritional assessment dated [DATE] revealed Resident #45 was down seven pounds in one month and 15.4 in three months for a significant weight loss. The weight loss was discussed with the Interdisciplinary Team and the resident was much more active moving around in the hallways in his wheelchair. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had intact cognition and had lost weight. He was not on a prescribed weight loss regimen. On 12/18/24 at 11:10 A.M. an 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 resident interview, medical record review, policy review and staff interview the facility failed to ensure resident care conferences were completed quarterly. This affected two (Residents #34 and #56) of two residents reviewed for care conferences. The facility census was 74. Findings include: 1. Review of Resident #56's medical record revealed an admission date of 09/25/23 with diagnoses that included pressure ulcer to the sacrum, diabetes mellitus and chronic kidney disease. Review of Resident #56's Minimum Data Set (MDS) 3.0 quarterly assessment revealed an intact and independent cognition level. Further review of the medical record including progress notes revealed care conferences documented as completed on 07/25/24 and 01/23/24. No other notes related to care conferences were noted. Interview with Resident #56 on 12/16/24 at 10:40 A.M. revealed he had not been to any care conferences with the facility. Interview with Social Services Designee (SSD) #119 on 12/17/24 at 11:50 A.M. revealed care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview the facility failed to ensure a discharge summary (recapitulation of stay, final summary of the resident stay, reconciliation of medications, and post-discharge plan of care) was completed upon resident discharge/transfer from the facility. This affected one (Resident #124) of two residents reviewed for discharge. Findings included: Closed record review revealed Resident #124 was admitted to the facility on [DATE] and discharged on 12/12/24 with diagnoses including displaced fracture of upper end of right humerus, hypertension, hyperlipemia, atrial fibrillation, gastro-esophageal reflux disease, bradycardia, hypothyroidism, benign prostatic hyperplasia with lower urinary tract symptoms, diabetes, kidney failure, difficulty walking, and muscle wasting, falls, lack of coordination, and presence of cardiac pacemaker. Review of Resident #124 medical record revealed no evidence of a discharge summary (recapitulation of stay, final summary of the resident stay,…

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, medical record review, and policy review, the facility failed to ensure Resident #73 received timely and appropriate surgical wound care. This affected one (Resident #73) of one resident reviewed for non-pressure skin alterations. The facility census was 74. Findings include: Review of the closed medical record for Resident #73 revealed an admission date of 09/19/24 and a discharge date of 11/04/24. Medical diagnoses included osteomyelitis of vertebra, infected surgical site, type two diabetes mellitus, peripheral neuropathy, low back pain, localized swelling, and arthritis due to other bacteria of the left hand. Review of Resident #73's admission assessment dated [DATE] revealed the resident had a surgical dehiscence (the bursting or splitting open of a wound) wound on the lumbar back measuring 24.0 centimeters (cm) by 7.5 cm by 2.0 cm. Review of Resident #73's admission orders (from the hospital) dated 09/19/24 revealed no evidence of wound care order for the surgical incision on the spine,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, interview, and policy review the facility failed to ensure pressure ulcer treatments were completed per orders. This affected one (Resident #73) of four residents reviewed for pressure ulcers. Findings included: Closed record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, opioid use, infected surgical site, type two diabetes, anemia, pressure ulcer to sacral region, mass and lump to left lower limb, and arthritis due to other bacteria left hand. Review of Resident #73's hospital orders dated 09/19/24 revealed to cleanse sacrum wound with mild soap and water, apply Triad hydrophilic paste dime thick to sacrococcygeal area twice daily and as needed. The Triad paste doesn't need to remove completely with cleaning. There was no evidence this order was written on admission to the facility or administered according to the treatment administration record (TAR). Review of admission skin assessment dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure restorative nursing programs were monitored and assessed quarterly. This affected one (Resident #58) of three residents reviewed for mobility. The facility census was 74. Findings include: Review of Resident #58's medical record revealed an admission date of 05/11/23 with diagnoses including cellulitis to the left lower leg, legal blindness, arthritis, hypertension, and depression. Review of Resident #58's restorative care plan dated 03/25/24 revealed the resident received a passive range of motion (PROM) exercise program to his lower extremities five to seven days per week, for 15 minutes per session. Review of Resident #58's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was assessed to have intact cognition with a Brief Interview for Mental Status (BIMS) score of a 15 out of 15. Resident #58 required assistance from staff to complete activities of daily living…

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, policy review, and interview the facility failed to maintain hot water temperatures in a safe manner to prevent potential accident/resident burns. This affected two (Residents #14 and #51) of 13 residents whose water temperatures were obtained. Findings include: On 12/18/24 from 4:34 P.M. to 4:36 P.M. observation of the water temperature in Residents' #14 and #51 room revealed the water temperature was 123.6 degrees Fahrenheit (F). The residents in the rooms were not available for an interview. The Maintenance Director (MD) obtained the water temperature using the facility's digital thermometer in the presence of the surveyor and confirmed the water temperature during observation. Review of the facility undated policy and procedure for water temperatures revealed hot water temperatures meet regulatory requirements in Ohio of 105-120 (F). The policy and procedure did not include a procedure if water temperatures didn't meet regulatory requirements. Interview on 12/18/24 at 5:05 P.M., with the Administrator revealed the facility did not have an action plan 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 medical record review, observation, and interview the facility failed to ensure residents were adequately assessed and treated for urinary incontinence and failed to ensure residents had adequate indication for use of an indwelling urinary catheter. This affected two (Resident #73 and #57) of three residents reviewed for bladder/bowel and catheters. Findings included: 1. Closed record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, opioid use, acute subacute infective endocarditis, endocarditis (valve), infected surgical site, type two diabetes, bipolar, anemia, pressure ulcer to sacral region, alcohol dependence, low back pain, localized swelling, mass, and lung to left lower limb, and arthritis due to other bacteria left hand. The resident was discharged on 11/04/24. Review of Resident #73's admission assessment dated [DATE] revealed the resident was incontinent of bladder and bowel. There was no evidence of a comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, and interview the facility failed to ensure residents were provided a comprehensive and individualized plan to monitor and address significant weight loss. This affected one (Resident #73) of four residents reviewed for nutrition. Findings included: Closed record review revealed Resident #73 was admitted to the facility on [DATE] and was discharged on 11/04/24. The resident's diagnoses included osteomyelitis of vertebra, opioid use, acute subacute infective endocarditis, endocarditis (valve), infected surgical site, type two diabetes, edema, chronic obstructive pulmonary disease, heart failure, hypothyroidism, neuropathy, bipolar, anemia, pressure ulcer to sacral region, alcohol dependence, low back pain, localized swelling, mass and lump to left lower limb, and arthritis due to other bacteria left hand. Review of the admission assessment dated [DATE] revealed the resident had congestive heart failure (CHF) and had plus one pitting edema to bilateral lower extremities, the…

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

Based on Ombudsman interview, resident interview, medical record review and staff interview, the facility failed to provide timely assistance to Resident #56 to obtain state photo identification. This affected one (Resident #56) of one residents reviewed for social services assistance. The facility census was 74. Findings include: Review of Resident #56's medical record revealed an admission date of 09/25/23 with diagnoses that included pressure ulcer to the sacrum, diabetes mellitus and chronic kidney disease. Review of Resident #56's Minimum Data Set (MDS) 3.0 quarterly assessment revealed an intact and independent cognition level. Interview with the facility Ombudsman on 12/11/24 at 11:37 A.M. revealed concerns related to the facility not assisting Resident #56 in obtaining a state photo identification in a timely manner in order to gain access to his personal bank account. Interview with Resident #56 on 12/16/24 at 10:46 A.M. revealed he had not obtained a state photo identification in order to gain access to his personal bank account. Interview on 12/18/24 at 11:45 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to Resident #73 was free from significant medication errors. This affected one (Resident #73) of seven residents reviewed for medication administration. Findings include: Review of the closed medical record revealed Resident #73 was admitted to the facility on [DATE] and was discharged on 11/04/24. Medical diagnoses included osteomyelitis (bone infection) of the vertebra, opioid use, subacute infective endocarditis (infection of the hearts inner lining and/or heart valves), an infected surgical site, type two diabetes mellitus, low back pain, and arthritis due to other bacteria of the left hand. Review of Resident #73's record revealed the resident was hospitalized for a blood transfusion on 09/27/24 and returned on 09/28/24. Resident #73 also had a hospital stay of less than 24 hours on 10/13/24. Review of Resident #73's admission assessment dated [DATE] revealed the resident had a surgical dehiscence (the bursting or splitting open of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff, the facility failed to ensure a pneumonia vaccine was given to Resident #45 after consent. This affected one resident (Resident #45) of five residents reviewed for vaccinations. The facility census was 74. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included hypokalemia, bulbous ureteral stricture hematuria, benign prostatic hyperplasia, retention of urine, diabetes, hyperlipidemia, respiratory failure, atrial fibrillation, osteoarthritis, major depressive disorder, and dementia. Further review of the medical record revealed no evidence Resident #45 was administered the pneumonia vaccine. Review of the Consent for Immunizations of Pneumonia dated 06/28/24 revealed Resident #45 consented to receiving the pneumonia vaccine on 06/28/24. Review of the June 2024 Medication Administration Record (MAR) revealed Resident #45 had not received the pneumonia vaccine. Review of the July…

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, hospice provider self-reported incident review, review of a facility self-reported incident investigation, and staff interview, the facility failed to thoroughly investigate an allegation of missing narcotic medications. This affected one (Resident #8) of three residents reviewed for narcotic medication use. The facility census was 73 Findings include: Review of Resident #8's medical record revealed an admission date of 12/27/23 with diagnoses that included rheumatoid arthritis, adult failure to thrive and hypertension. Further review of the medical record revealed on 04/19/24 Resident #8 was prescribed the use of morphine sulfate (Roxanol, opioid analgesic medication) 20 milligram (mg) per one milliliter (ml) 0.25 ml every two hours as needed for pain. Review of the Medication Administration Record (MAR) revealed a total of 31 doses of medication administered between 04/21/224 and 07/19/24. Thirty-one 0.25 ml doses from a 30 ml bottle would equal 22.25 ml remaining in the 30 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, hospice provider self-reported incident, facility self-reported incident investigation, and staff interview, the facility failed to accurately document medication administration in the medical record and controlled drug administration records. This affected one (Resident #8) of three residents reviewed for narcotic medication use. The facility census was 73 Findings include: Review of Resident #8's medical record revealed an admission date of 12/27/23 with diagnoses that included rheumatoid arthritis, adult failure to thrive and hypertension. Further review of the medical record revealed on 04/19/24 Resident #8 was prescribed the use of morphine sulfate (Roxanol, opioid analgesic medication) 20 milligram (mg) per one milliliter (ml) 0.25 ml every two hours as needed for pain. Review of the MAR revealed a total of 31 doses of medication were administered…

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, self-reported incident review, and staff interview the facility failed to timely report an allegation of sexual abuse and failed to report an allegation of misappropriation to the state survey agency. This affected two residents (Resident #1 and Resident #50) of three residents reviewed for abuse. The facility census was 75. Findings include: 1. Review of the Final Decree of Adjudication of Incapacity and Appointment of Plenary Guardian of the Person and Estate document dated January 15, 2003, revealed Resident #1 was adjudged and decreed an incapacitated person and her parents were appointed as guardians. Review of Resident #1's medical record revealed an admission date of 08/04/21 with diagnoses including schizophrenia, adjustment disorder, anxiety, unspecified psychosis not due to a substance or known physiologic condition, depression, unspecified lack of coordination, difficulty walking and sleep disorder. Review of the annual Minimum Data Set (MDS) 3.0 Assessment, dated 07/05/24,…

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 test tray, the facility failed to serve palatable chicken. This had the potential to affect all the residents in the facility except two residents (#36, #69) who do not receive nourishment from the kitchen. The facility census was 77 residents. Findings include: Observation of meal service on 07/10/24 at 11:28 A.M. revealed the chicken breast served to Resident #6 appeared dry. Resident #7 revealed he was ordering out because his chicken was dry. Resident #2 said he did not like the meal and was ordering a substitute. Observation of the kitchen on 07/10/24 at 11:42 A.M. revealed the tray line was finishing. The facility ran out of asparagus and provided green beans instead. There were less than a dozen chicken breast remaining. There was no juice in the pan with the chicken and the outside appeared dry. Interview on 07/10/24 at 11:44 A.M. interview with [NAME] #155 revealed he baked the chicken about 30 minutes. On 07/10/24 at 11:46 A.M. a chicken breast was tasted for palatability. The temperature of the chicken breast was 153.4 degrees. The…

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

Based on interview, observation, and invoice review, the facility failed to ensure the facility was administered in a manner to enable it to use its resources effectively to maintain the highest practicable well being of each resident when the facility transport van has not been available for resident use for over one year. This had the potential to affect all the residents in the facility. The resident census was 77. Findings include: During the course of the investigation, the surveyor observed and determined the facility did not have transportation available to transport a resident to a doctor appointment. It was discovered the facility did not have a van for transportation or activities. Interview on 07/10/24 at 9:47 A.M. with the Administrator revealed the facility does not have a company van to use for transportation. They have not had a functioning van for about a year. Review of facility provided documentation and invoice revealed the lift in the facility van broke in June 2022. The van was out of service until 04/20/23 when it was repaired. Review of an email dated 07/11/24…

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, policy review, and interview, the facility failed to ensure sanitary pericare technique and availability of soap in the kitchen at the handwashing sink. This affected one resident (#5) who received personal care from staff and had the potential to affect all the residents in the facility except for two residents (#36, #69) who do not receive nourishment from the kitchen. The facility census was 77. Findings include: 1. Observation on 07/10/24 at 3:15 P.M. of pericare for Resident #5 took place with State Tested Nurse Aides (STNA) #132 and #108. After both STNA's gowned and gloved STNA #132 revealed the facility used periwash spray on a disposable wipe to cleanse the resident wiping from front to back, changing areas on the cloth and then dried with a towel. STNA #108 rolled the resident onto her left side. STNA #132 cleaned the bowel movement with a disposable wipe wet with periwash. After cleaning the bowel movement State Tested Nurse Aide (STNA) #132 pulled the sheet and blanket up to the residents' chest before changing her gloves. She was wearing the same…

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, activity calendar review, and record review, the facility failed to ensure residents right to self determination when the facility van was not available to transport residents to the bank, appointments and community activities. This affected two residents (#2,#10) of three residents reviewed for banking transportation and one resident (#6) of three residents reviewed for medical appointment transportation. Findings include: 1. Record review of Resident #6 revealed a [DATE] admission with diagnoses including major depressive disorder, Vitamin D deficiency, muscle weakness, alcoholic polyneuroparthy, iron deficiency anemia, and anxiety disorder. Review of the [DATE] Quarterly Minimum Data Set Assessment included the resident was independent for daily decision making, and walked with supervision. Review of [DATE], 2:50 P.M. nurse note entered by Registered Nurse (RN) #146 revealed the resident had new appointments for a mammogram on [DATE] at 12:45 P.M. and the Pain Center on [DATE] at 8:48 A.M.…

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 interview, the facility failed to ensure resident mail and packages was delivered unopened and on the weekends. This affected three residents (#2, #6 and #7). Findings include: 1. Review of Resident #6's medical record revealed a 01/16/24 admission with diagnoses including major depressive disorder, Vitamin D deficiency, muscle weakness, alcoholic polyneuroparthy, iron deficiency anemia, and anxiety disorder. Review of the 05/27/24 Quarterly Minimum Data Set Assessment included the resident was independent for daily decision making, and walked with supervision. Interview on 07/10/24 at 9:01 A.M. with Resident #6 revealed the resident has been attempting to get social security disability to get into an assisted living on a waiver. Two weeks ago Social Services Designee (SSD) #105 brought her mail from the social security office that had been opened with a clean cut like a letter opener. When she asked why it was opened she said sometimes people here try to outrun the system and open mail. Interview on 07/10/24 at 9:40 A.M. with Human Resources #145 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure new interventions were attempted to prevent recurring urinary tract infections. This affected one resident (#5) of three residents reviewed for urinary tract infections. Findings include: Review of Resident #5's medical record revealed a 09/25/23 admission with diagnoses including chronic congestive heart failure, type 2 diabetes, gastro-esophageal reflux disease, hypertension, hypothyroidism, angina pectoris, moderate protein calorie malnutrition, ischemic cardiomyopathy, transischemic attack and cerebral infarction, depression, dysphasia, obstructive and reflux uropathy, non-rheumatic mitral valve stenosis and altered mental status. Review of a 05/19/24 quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision-making, dependent for toileting, personal hygiene and bathing. The resident had an indwelling urinary catheter at the time of the assessment and was frequently incontinent of bowel. The resident had…

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

Based on menu review, dislike list, interviews, and photo, the facility failed to ensure a nourishing, palatable well balanced diet was served. This affected one resident (#6) of three residents reviewed for nourishing diets. Findings include: Review of Resident #6's medical record revealed a 01/16/24 admission with diagnoses including major depressive disorder, Vitamin D deficiency, muscle weakness, alcoholic polyneuroparthy, iron deficiency anemia, and anxiety disorder. Review of the 05/27/24 Quarterly Minimum Data Set Assessment included the resident was independent for daily decision making, and walked with supervision. Interview on 07/10/24 at 9:01 A.M. with Resident #6 revealed on 05/27/24 she received a roll and mashed potatoes for supper. The resident had a time stamped photo of her meal tray. On 06/25/24 the resident received plain spaghetti noodles and peaches on her supper tray. Interview on 07/10/24 at 12:11 P.M. with Culinary Director #115 revealed it is possible to get only a few food choices or no entree on a meal tray. Culinary Director #115 indicated the computer…

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

Based on medical record review, observation, interview, and policy review the facility failed to ensure medications were properly stored and secured. This affected Resident #24 with the potential to affect all 69 residents residing in the building. Findings included: 1. Observation on 03/29/24 at 7:43 A.M. revealed there was a medication cart left unlocked and unattended. The medication cart was in the main area of the building where residents sit and the area serves as the nursing station for all the nurses and the main desk. Interview on 03/29/24 at 7:44 A.M. with Licensed Practical Nurse (LPN) #190 confirmed the cart was unlocked and unattended. The LPN reported she was not sure who the nurse was that was responsible for the medication cart, however she would lock the cart. Interview on 03/29/24 at 11:41 A.M. with the Director of Nursing (DON) confirmed LPN #190 reported to her that the medication cart was left unlocked and unattended. LPN #127 confirmed with the DON she was the one that had left the medication cart unlocked and unattended. 2. Medical record review revealed…

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

Based on medical record review, review of administration detail report, interviews, and policy review the facility failed ensure a resident received pain medication as ordered. This affected one (Resident #24) of one reviewed for pain management. Findings included: Medical record review revealed Resident #24 was admitted to the facility 10/10/19 with diagnoses including diffuse traumatic brain injury, idiopathic peripheral autonomic neuropathy, quadriplegia, muscle spasm, and opioid abuse in remission. Review of Resident #24's pain observation tool dated 01/12/24 revealed the resident verbalized and/or exhibited non-verbal symptoms of pain. The pain was worse in the morning, afternoon, evening, and night. The pain was sharp and chronic. The resident was able to verbally express their pain level. The resident reported the severity of pain was five out of 10 on the pain scale. The resident receives scheduled Oxycodone. Review of Resident #24's orders dated 03/20/24 revealed Percocet 7.5-325 milligrams (mg) once a day for pain and additional order for four times a day for pain. Further…

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, review of narcotic control sheet, review of administration detail report, interview, and policy review the facility failed to ensure medication administration was accurately documented. This affected one (Resident #24) of one reviewed for pain management. Findings included: Interview on 03/29/24 at 9:19 A.M., with Resident #24 revealed she had requested her 8:00 A.M. scheduled pain pill at 8:20 A.M. and Licensed Practical Nurse (LPN) #127 did not administer her medication until now. Review of Resident #24's narcotic control sheet for Percocet 7.5-325 milligrams revealed on 03/29/24 the Percocet was administered at 8:00 A.M Review of Resident #24's administration detail report sheet dated 03/29/24 revealed LPN #127 administered Resident #24's Percocet at 8:40 A.M Interview on 03/29/24 at 9:21 A.M. with LPN #127 reported she had administered Resident #24's Percocet at 9:01 A.M LPN #127 confirmed she signed off the Percocet on the narcotic sheet at 8:00 A.M. which did not reflect the actual time she administered it. Review of the facility policy titled…

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 interview with the staff the facility failed to maintain a sanitary kitchen. This affected all residents but two residents ( Resident #29 and #63) who did not receive food from the facility kitchen. The facility census was 71 residents. Findings include: 1. Observations on 12/28/23 at 10:00 A.M. revealed [NAME] #603 was preparing pureed spinach for lunch with out a hair net on. He verified at 10:02 A.M. he did not have one on. Review of the undated facility policy titled, Staff Attire, revealed all staff members would have their hair off their shoulders, confined in a hair net or cap and facial hair would be restrained. All staff would exhibit appropriate personal hygiene. 2. Observation on 12/28/23 at 10:05 A.M. [NAME] #603 was placing lunch into the steamtable, however, there was dried up scrambled eggs and food debris littering the steam table and preparation area. This was verified by [NAME] #603 at 10:05 A.M. 3. Observations during a tour of the kitchen on 12/28/23 at 10:08 A.M. with Dietary Manager (DM) #604 revealed the back splash behind 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 record review, interview, and policy review, the facility failed to ensure residents were adequately protected from abusive behavior by other residents. This affected two (Resident #50 and #66) of five residents reviewed for abuse. The facility census was 77. Findings include: 1. Review of Resident #50's medical record revealed diagnoses including diabetes mellitus, end stage renal disease, dementia, psychotic disturbance, mood disturbance, and anxiety. A care plan for activity of daily living (ADL) self care performance deficit initiated 02/13/22 indicated Resident #50 required supervision/set up assistance for ambulation, locomotion and transfers. A care plan initiated 11/02/22 indicated behaviors exhibited by Resident #50 were related to food complaints. A quarterly MDS assessment dated [DATE] indicated Resident #50 was cognitively intact with no behavioral symptoms. A nursing note dated 11/01/23 at 9:20 P.M. indicated Resident #50 and Resident #74 were arguing in the television lounge. As the nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to initiate a recommended restorative program to promote maintenance of a resident's ambulatory status. This affected one (Resident #26) of three residents reviewed for activities of daily living. The facility census was 77. Findings include: Review of Resident #26's medical record revealed diagnoses including depression, cerebrovascular disease, and occlusion and stenosis of the carotid artery. An admission nursing assessment dated [DATE] indicated Resident #26 required assistance with transfers, needed an ambulation device and required limited assistance to walk in her room. A plan of care initiated 05/13/22 indicated Resident #26 had a stroke with one side of her body affected. Interventions included monitoring for decline in activity of daily living status, therapy evaluations and treatments per orders and referring to restorative programs as needed. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 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, record review and interview, the facility failed to ensure treatments/interventions were applied according to physician orders. This affected three (Residents #35, #73, and #76) of four residents reviewed for wounds. The facility identified eight residents with non-pressure related skin impairment. The facility census was 77. Findings include: 1. Review of Resident #35's medical record revealed diagnoses including heart failure, type two diabetes mellitus, dementia, venous insufficiency and history of a diabetic foot ulcer. On 07/31/23 an order was written for Profo boots to be applied while up in the recliner and in the bed. On 10/24/23 an order was written to cleanse the left medial heel with normal saline, apply santyl (debriding agent) and cover with a border dressing every day. A wound report dated 11/14/23 indicated Resident #35 had a full thickness diabetic foot ulcer on the left medial heel which measured 2.5 centimeters (cm) x 3.2 cm x 0.1 cm with moderate drainage. On 11/21/23 at…

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

Based on observations, medical record review and interview, the facility failed to obtain a wound culture in accordance with orders. This affected one (Resident #75) of four residents reviewed for wounds. The facility identified eight residents with pressure ulcers. The facility census was 77. Findings include: Review of Resident #75's medical record revealed diagnoses including rhabdomyolysis (breakdown of skeletal muscle), nicotine dependence, and conversion disorder with seizures or convulsions. A nursing note dated 09/09/23 at 6:00 P.M. indicated Resident #75 had unstageable areas to the mid-scapula and sacral areas. A wound consult note dated 09/29/23 indicated the sacral wound was deteriorating. A note by an Advanced Practice Registered Nurse (APRN) on 10/12/23 indicated Resident #75 had multiple foul smelling wounds which she would have cultured. An order was written for a culture of the sacral wound. An APRN note dated 10/19/23 indicated Resident #75 continued to have moderate amount of wound drainage. The note indicated the wound culture did not appear to have been sent. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #13's oxygen tubing and humidifier bottle were changed weekly as ordered and failed to ensure Resident #11's oxygen tubing was changed weekly. This affected two (Resident #13 and #11) of three residents reviewed for respiratory care. The facility identified nine residents as receiving oxygen therapy. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, human immunodeficiency virus, asthma, and morbid obesity. Review of the Minimum Data Set (MDS) assessment, dated 10/27/22, revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 10, which indicated moderately impaired cognition. There were no behaviors or rejection of care. The resident received oxygen therapy. Review of the Care Plan, dated 01/07/23, revealed Resident #13 was at risk for altered respiratory status with the intervention 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, record review, and facility policy review, the facility failed to ensure food appropriately stored, prepared and distributed and failed to ensure the environment was clean and sanitary. This had the potential to affect all 53 residents who received food from the kitchen. The facility provided a diet list which revealed Residents #5, #40 and #60 did not receive food by mouth and did not receive food from the kitchen. The facility census was 56. Findings included: 1. Observation on 08/01/23 at 10:45 A.M. revealed four containers of possibly fruit salad and four containers of possibly apple crisp not labeled or dated. An interview at the time with the Culinary Director #86 revealed the possibly fruit salad was from 08/01/23 and should have been labeled and dated. He was not sure of the date for the possibly apple crisp but verified it should have been dated and labeled. Review of the facility policy titled, Food Storage: Cold Foods, revised 04/2018, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a…

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

Based on review of the facility's infection control logs, staff interview, and policy review, the facility failed to maintain an effective infection control program that adequately tracked infections within the facility to identify trends/ patterns when they occurred. They also failed to ensure indwelling urinary catheter care was completed in accordance with acceptable infection control practices to prevent the possible spread of infection. This affected one (Resident #115) of one residents reviewed for catheter care and had the potential to affect all residents in the facility. The facility's census was 56. Findings include: 1. A review of the facility's infection control logs for the past seven months (January 2023 through July 2023) revealed the facility's infection preventionist was not consistently identifying and recording the organism involved with infections that was recorded on the monthly logs. The first three months of 2023 (January through March) were reviewed and did not always have an organism identified when the log indicated a diagnostic tests had been completed…

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 insure a clean, comfortable and homelike environment. This affected ten residents (#1, #7, #12, #15, #21, #39, #56, #60, #115 and #265). The census was 56. Findings include: Observation of the facility with the Administrator 08/02/23 at 6:04 P.M. revealed: • The wall paper and door thresholds throughout the halls of the facility were in disrepair. The wall paper was torn off the walls, especially around the doorways of the rooms. The door frames had the paint scratched off. • The halls of the facility did not have fresh air. The halls had an odor of staleness, body odor, dirty clothes and uncleanliness. • Resident #115 is in a low bed with the left side of the bed against the wall. The wall he would be looking at when lying on his left side had drywall damage and needed painted. • Resident #265's bed faced the bathroom door. The door had a great amount of paint damage making it an unsightly focal point. • Resident #12 had two 1.5 foot by six inches gouges in the wall exposing the drywall. There was a four foot…

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, policy review, and interview, the facility failed to ensure an accurate Level I Pre-admission Screening/Resident Review (PASRR) was completed and did not submit a resident with a mental health disorder or intellectual disability for a Level II review for additional services. This affected two residents (#30 and #56) of two residents reviewed for PASRRs. This had the potential to affect 20 residents with diagnoses of mental health disorder or intellectual disabilities. The facility census was 56. Findings included: 1. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, gastro-esophageal reflux disorder, hypertension, obstructive sleep apnea, neuromuscular dysfunction of bladder, hyperlipidemia, major depressive disorder, unspecified psychosis, schizophrenia, and epilepsy. Review of a quarterly minimum data set (MDS) completed on 07/18/23 revealed Resident #30 had a brief interview for mental status…

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 residents' complete comprehensive care plans included care plans to address constipation, oxygen use, and anxiety/ psychoactive medication use. This affected four residents (#21, #34, #39, and #56) of 22 residents reviewed for care plans. The facility census was 56. Findings include: 1. A review of Resident #21's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizophrenia, adjustment disorder, anxiety disorder, unspecified psychosis, muscle weakness, difficulty in walking, and need for assistance with personal care. A review of Resident #21's physician's orders revealed the resident was ordered to receive Colace (a stool softener) 100 milligrams by mouth every morning for constipation. The order had been in place since 10/04/22. She also had an order to receive Lactulose (a laxative) 20 Grams/ 30 milliliters by mouth twice a day for constipation. That order had been in place since 08/04/21. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to provide residents with the ability to participate in the development of their comprehensive care plans within 72 hours upon resident admission to the facility and quarterly thereafter. This affected four residents (#7, #30, #48 and #55) of four residents reviewed for care planning. This facility census was 56 residents in the facility. Findings included: 1. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, gastro-esophageal reflux disorder, hypertension, obstructive sleep apnea, neuromuscular dysfunction of bladder, hyperlipidemia, major depressive disorder, unspecified psychosis, schizophrenia, and epilepsy. Review of a quarterly minimum data set (MDS) completed on 07/18/23 revealed Resident #30 had a brief interview for mental status (BIMS) of 15, indicating no cognitive impairment. Interview on 07/31/23 at 3:24 P.M. with Resident #30 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interview, the facility failed to ensure residents with current pressure ulcers and residents at risk for developing pressure ulcers were assessed, turned and repositioned and had treatment ordered for pressure areas. This affected three residents (#12, #40, and #55) of three residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. Findings include: 1. Review of Resident #40's medical record revealed a 09/17/19 admission with diagnoses including acute respiratory failure with hypoxia, idiopathic peripheral neuropathy, tracheostomy, quadriplegia, aphasia, cognitive communication deficit, dysphasia, right and left foot drop, anxiety disorder, need for assistance with personal care, and contracture's of right and left hands. The resident had an at risk for impaired skin plan of care initiated 10/06/21 due to immobility, incontinence, tube feed, tracheostomy, and diagnosis of traumatic brain injury. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's infection control logs, infection control surveillance criteria reports, record reviews, staff interview, and policy review, the facility failed to ensure antibiotics were not used unnecessarily and without an adequate indication for use. This affected five residents (#12, #29, #40, #49, and #215) of seven residents reviewed for antibiotic use. Findings include: 1. A review of the facility's infection control log for January 2023 revealed Resident #215 was recorded on the log as having had a facility acquired urinary tract infection (UTI) that was not catheter related. The date of symptom onset was not identified on the log, but the resident was marked as having had dysuria as a symptom. The infection control log indicated laboratory testing was completed. The resident was started on Cephalexin 500 milligrams (mg) every six hours for seven days. The infection control log did not identify what the organism was that caused the UTI that should have been identifiable with laboratory…

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 ensure advanced directives were accurately documented for a resident. This affected one resident (#26) of three residents reviewed for advanced directives. The facility census was 56. Findings included: Review of Resident #26's medical record revealed she was admitted on [DATE] with diagnoses including Huntington's Disease, dementia in other diseases classified elsewhere, gastro-esophageal reflux disease, hyperlipidemia and generalized muscle weakness. Further review of her medical diagnosis form revealed she had chosen Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) for her advanced directives. Review of Resident #26's physician order, dated 04/12/23, identified an order for DNR-CCA. Review of Resident #26's plan of care, dated 12/02/21, revealed she was a Do Not Resuscitate - Comfort Care (DNR-CC) advanced directive. Review of Resident #26's State of Ohio Do Not Resuscitate (DNR) form, dated 01/22/19, in the binder at 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, record review, and facility policy review, the facility failed to ensure residents were sufficiently prepared for transfer to a local emergency room. This affected two residents (#35 and #49) of three residents reviewed for hospitalization. The facility census was 56. Findings included: 1. Review of Resident #35's medical record revealed he was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, essential hypertension, hyperlipidemia, type two diabetes, and generalized muscle weakness. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/15/23, revealed he was cognitively impaired. Review of Resident #35's progress note, dated 06/22/23 and timed 6:37 P.M., revealed he was found on the floor beside of the bed. He stated he had hit his head on the floor and was dizzy. Resident #35's physician was notified, and he was sent out to local hospital. Review of Resident #35's progress notes…

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 ensure a Resident's Preadmission Screening and Resident Review (PASRR) was updated when a new mental health diagnosis was added. This affected one resident (#56) of six residents reviewed for PASRR and unnecessary medications. The facility census was 56. Findings included: Review of Resident #56's medical record revealed he was admitted to the facility on [DATE] with diagnoses including vascular dementia, essential hypertension, chronic kidney disease, major depressive disorder (entered 02/28/23), and unspecified psychosis not due to a substance or known physiological condition (entered 07/14/23). Review of Resident #56's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/06/23, revealed he was cognitively impaired, had an active diagnosis of depression, and took an antipsychotic medication seven days and an antidepressant medication seven days during the seven day look back period. Review of Resident #56's physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's activity calendar, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided the opportunity to attend activities of her preference to improve her quality of life while residing in the facility. This affected one resident (#17) of four residents reviewed for activities. Findings include: A review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, generalized anxiety disorder, adjustment disorder with mixed anxiety and depression, chronic obstructive pulmonary disease, and difficulty walking. A review of Resident #17's annual activity assessment dated [DATE] revealed the resident had a current interest in card games, religious activities/ bible studies, and group activities. She preferred activities in the afternoons and evenings and her preferred activity setting was the day/ activity room or in her own room. 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, record review, review of facility elopement documentation, and facility policy review, the facility failed to ensure a cognitively impaired, mobile resident had adequate supervision and did not elope from the facility. This affected one resident (#29) of two residents reviewed for accidents. The facility census was 56. Findings included: Review of Resident #29's medical record revealed she was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, unspecified disorientation, essential hypertension and unspecified dementia. Review of Resident #29's annual Minimum Data Set (MDS) 3.0 assessment, dated 05/08/23, revealed she was cognitively impaired and needed supervision and set up help only with bed mobility, transferring, walking in room, walking in corridor, locomotion on the unit, and locomotion off the unit. Further review revealed wandering behavior was not exhibited during the seven day look back period. Review of Resident #29's Wandering Observation…

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 facility policy review, the facility failed to ensure confirmation of PEG (percutaneous endoscopic gastrostomy) tube placement prior to the administration of medications. This affected one resident (#40) of one resident observed for medication administration through a PEG tube. The facility census was 56. Findings included: Review of Resident #40's medical record revealed an initial admission of 09/01/19 and a readmission on [DATE] with diagnoses including acute respiratory failure with hypoxia, quadriplegia, essential hypertension, personal history of traumatic brain injury, and gastrostomy status. Review of Resident #40's annual Minimum Data Set (MDS) 3.0 assessment, dated 07/06/23, revealed he was rarely/never understood, had a short-term and long-term memory problem, his ability to make decisions regarding tasks of daily living was severely impaired, and he had a feeding tube. Review of Resident #40's physician order, dated 07/24/23, identified he was to receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident with a tracheostomy tube had all the necessary tracheostomy equipment/ supplies needed for emergencies as ordered by the physician and as per the plan of care. This affected one resident (#34) of two residents reviewed with tracheostomies. Findings include: A review of Resident #34's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, acute on chronic respiratory failure, and tracheostomy status. A review of Resident #34's physician's orders revealed he had an order to receive humidified oxygen at 5 liters per minute (LPM) via trach mask. He also had an order to be suctioned every shift and as needed (prn). His orders included the need to maintain an Ambu bag (resuscitative device that could be attached to the tracheostomy to administer rescue breathing in the event of a respiratory arrest) oxygen (e.g. an E-cylinder), 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, policy review, and interview, the facility failed to provide medically related social services to ensure a resident maintained highest practicable mental and psychosocial well-being. This affected one resident (#55) of one resident reviewed for mood status. This had the potential to affect 34 residents with a Patient Health Questionnaire 9 (PHQ-9) score of 10 or higher. The facility census was 56. Findings included: Record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, hyperlipidemia, fracture of lower end of right femur, hypertension, and depression. Review of a comprehensive admission minimum data set (MDS) completed on 01/03/23 revealed Resident #55 had a PHQ-9 score of 6, indicating mild depression. Review of a quarterly MDS completed on 03/22/23 revealed Resident #55 had a PHQ-9 score of 13, indicating moderate depression. A quarterly MDS completed on 04/18/23 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure medications ordered on an as needed (prn) basis for hypertension and pain included appropriate parameters to direct the nurse on when to administer the medications. This affected one resident (#34) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #34's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure) and amputations of his bilateral legs above the knee, and adult inset diabetes mellitus with diabetic neuropathy. A review of Resident #34's physician's orders revealed he had orders in place to receive Clonidine HCL 0.1 milligrams (mg) by mouth every 12 hours as needed for hypertension. The order had been in place since 06/16/23 and did not include any parameters from the physician to direct the nurse on when to administer it. There was no order to administer if the resident's systolic blood pressure (SBP) or diastolic…

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 ensure psychotropic medications were used for an appropriate indication and administered as ordered. This affected two residents (#31 and #56) of five residents reviewed for unnecessary medications. The facility census was 56. Findings included: 1. Review of Resident #56's medical record revealed he was admitted to the facility on [DATE] with diagnoses including vascular dementia, essential hypertension, chronic kidney disease, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition (added 07/14/23). Review of Resident #56's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/06/23, revealed he was cognitively impaired, had an active diagnosis of depression, and took an antipsychotic medication seven days and an antidepressant medication seven days during the seven day look back period. a. Review of Resident #56's physician order, dated 03/01/23, revealed he was to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure they were free from a medication error rate of 5% or more. This affected one resident (#40) of four residents observed for medication administration. This resulted in three errors in medication administration out of 27 opportunities for error resulting in a medication error rate of 11.11%. The facility census was 56. Findings included: Review of Resident #40's medical record revealed an initial admission of 09/01/19 and a readmission on [DATE] with diagnoses including acute respiratory failure with hypoxia, quadriplegia, essential hypertension, personal history of traumatic brain injury, and gastrostomy status. Review of Resident #40's annual Minimum Data Set (MDS) 3.0 assessment, dated 07/06/23, revealed he was rarely/never understood, had a short-term and long-term memory problem, his ability to make decisions regarding tasks of daily living was severely impaired, and he had a feeding tube. Review of Resident #40's…

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