Xenia Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a significant change Minimum Data Set (MDSs) assessment was completed for a resident that admitted to hospice. This affected one (#43) of 15 residents reviewed for MDS accuracy. The facility census was 34. Review of Resident #43's chart revealed Resident #43 was admitted to the facility on [DATE] with malignant neoplasm of bladder, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, anemia, atrial fibrillation, hyperlipidemia, history of falling, muscle weakness, hypokalemia, retention of urine, hydroureter and sepsis. Resident #43 was discharged from the facility on 07/05/25. Review of Resident #43's MDS assessments from 06/16/25 to 07/05/25 revealed Resident #43 did not have a significant change MDS assessment transmitted or completed upon Resident #43's admission to hospice services on 06/19/25. Review of Resident #43's quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a significant change in status Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a new mental health diagnosis. This affected one (#23) of the two residents reviewed for PASARRs. The facility census was 34. Review of Resident #23's medical record revealed that he was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, dysphagia, diabetes mellitus type 2, blindness in the right eye, congestive heart failure, bipolar disorder, anxiety, depression, malnutrition and dementia. Review of Resident #23's facility assessments from March 2025 to July 2025 revealed Resident #23 did not have a significant change PASARR completed for diagnosis of bipolar disorder. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment, dated 04/30/25, revealed the resident had cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. Review…

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, interviews, observations, and policy review, the facility failed to ensure residents, who were unable to carry out activities of daily living (ADLs) were provided grooming for facial hair. This affected one (#38) resident of three reviewed for ADLs. The facility census was 34.Review of the medical record for Resident #38 revealed an admission date of 01/02/25. Diagnoses included type II diabetes mellitus (DM II), altered mental status, and schizophrenia. Review of the care plan dated 01/08/25 revealed Resident #38 had an ADL self-care performance deficit related to weakness, history of being a victim of physical abuse by a family member, and trauma. Interventions included assistance with bathing/showering, setup with bed mobility, dressing, and eating, encouraged to use call light for assistance, and used walker to maximize independence with transferring.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had severe cognitive…

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, interviews, and policy review, the facility failed to ensure medications were within expiration date in the medication cart. This had the potential to affect three (#02, #06, and #15) of the three residents who were administered Pro-Stat. The facility census was 34. Observation on [DATE] at 3:11 P.M. with Licensed Practical Nurse (LPN) #803, revealed the [NAME] Hall medication cart had a Pro-Stat (albuterol) inhaler opened and was expired. The manufacturer's expiration date was marked as [DATE]. Interview with LPN #803 at the same time, verified the Pro-Stat inhaler had expired and needed to be discarded.Observation on [DATE] at 3:23 P.M. with LPN #30, revealed the Emerald Hall medication cart had a Pro-Stat inhaler that was opened and expired. The manufacturer's expiration date was marked as [DATE]. Interview with LPN #30 at the same time, verified the Pro-Stat inhaler had expired and needed to be discarded.Review of the facility policy titled, Medication Storage and Labeling, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a cognitively impaired resident was explained or understood an Arbitration Agreement prior to signing the agreement. This affected one (#38) of the three residents reviewed for arbitration agreements. The facility census was 34. Review of Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with adult physical abuse confirmed subsequent encounter, rectal prolapse, hypertension, schizophrenia, and altered mental status.Review of Resident #38's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #38 had a BIMS score of a one indicating Resident #38 was severely cognitively impaired. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #38's undated arbitration agreement revealed Resident #38 signed the arbitration agreement that stated she was agreeing to arbitration and waving her…

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

Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident room was free from holes in wall, free from broken drywall, and free from black debris on the wall. This affected one (#16) out of the three residents reviewed for cleanliness of rooms. Additionally, the facility also failed to ensure the shower rooms were free from black substance along the flooring near the walls. This had the potential to affect 19 (#17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) residents who use the shower room on the Emerald and [NAME] Halls. The facility census was 35. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/12/23 with medical diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, Intellectual Disabilities, and hypertension. Review of the medical record for Resident #16 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/14/25, which indicated Resident #16 had severely impaired cognition and required set-up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Legionella Water Management Plan, review of Water Management Evaluation Tool, interviews, and policy review, the facility failed to follow public health authority recommendations to revise the Water Management Plan in a timely manner and failed to monitor pH levels of water sources. This had the potential to affect all residents. The facility census was 40: Findings include: Review of Legionella Water Management Plan dated [DATE] revealed the facility identified members of the Water Management Team with the exception of naming the Maintenance Director; described the buildings water systems including circulation of water, number of mixing valves and hot water tanks, absence of holding tanks, points of recirculation, and location of tees; and listed the verification process including weekly checks and documentation of pH levels and water temperatures and flushing unused sinks and showers. There were no parameters listed for how long unused sinks and showers were flushed and no parameters for pH…

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 policy, the facility failed to assess residents identified prior to admission as a fall risk and failed to thoroughly investigate a fall. This affected two (Residents #38 and #43) of three residents reviewed for falls. The facility census was 42. Findings include: 1. Record review for Resident #38 revealed he was admitted to the facility on [DATE]. His diagnoses included hypertensive crisis, essential primary hypertension, hemiplegia, gout, spinal stenosis, and syncope. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively impaired. Resident #38 was dependent on staff for medication administration, bathing, and toileting. He required assistance from staff with eating, oral hygiene, and personal hygiene. Review of Resident #38's hospital referral prior to entering the facility stated Resident #38 was a high fall risk. Review of Resident #38's assessment titled, Fall Risk Assessment, dated 06/12/24 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 observations, staff interview, and facility policy review, the facility failed to properly store food in the dry storage area. This had the potential to affect all 37 residents who received food from the kitchen. The facility census was 37. Findings include: Observations of the kitchen on 11/19/23 at 9:40 A.M. with Kitchen Staff #320 revealed the dry storage area had seven unopened 12-ounce (oz) cans of carnation evaporated milk with the manufacturer's use by date of 06/13/22. One unopened 32-oz box of buttermilk pancake mix with manufactures use by date of 07/08/23. There were four one-gallon jugs of honey mustard with facility received date marked 06/20/no year. Upon opening on of the lids of the honey mustard revealed an unsealed manufacturer's top leaking onto the plastic lid causing it to ooze onto the side of the jar. Interview with Kitchen Staff #320 on 11/19/23 at 9:45 A.M. verified the seven cans of evaporated milk, pancake mix, and honey mustard were expired and all of it needed to be disposed of. Interview on 11/27/23 at 9:55 A.M. with the Administrator stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, family, and staff interviews, policy and procedure review, observations, and record review, the facility failed to provide a safe, clean homelike environment for Resident #12. This affected one (Resident #12) of three residents reviewed for a clean and homelike environment. The facility census was 37. Findings include: Review of Resident #12's medical record revealed an admission date of 10/24/23 with diagnosis including major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had intact cognition and no rejection of care. Review of Resident # 12's plan of care dated 10/31/23 revealed it was silent for refusal of cleaning services, preferences of not utilizing trash receptacles, or requests of personal item placement for utilization. Observation of Resident #12's room on 11/19/23 at 8:52 A.M. revealed the resident was lying in bed with her eyes closed. The floor under Resident #12's bed and surrounding floor area had a red dried…

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, facility policy review, and staff interview, the facility failed to administer a resident's wound treatments per physician orders. This affected one (Resident #3) of three residents reviewed for wounds. The facility census was 37. Findings include: Closed record review for Resident #3 revealed an admission date of 10/02/23. Diagnoses included peripheral vascular disease, obesity, type two diabetes mellitus, polyneuropathy, and wounds to left lower extremity and right great toe. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had intact cognition and had no behaviors and no rejection of care. Review of Resident #3's physician orders dated 10/03/23 and discontinued on 10/08/23 revealed an order to cleanse the left lower extremity with wound cleanser or normal saline, apply double layer of xeroform abdominal pads, and wrap with cling every night shift. Review of Resident #3's Treatment Administration Record (TAR) dated October 2023 revealed there was 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 medical record review, observations, and resident and staff interviews, the failed to provide a functional, and accessible call system for the residents. This affected two (Residents #12 and #16) of three residents reviewed for call light accessibility and functioning. The facility census was 37. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 10/24/23. Diagnoses included cellulitis of right lower limb, chronic kidney disease, venous insufficiency, lymphedema, acute respiratory failure with hypoxia, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had intact cognition and had no rejection of care. Resident #12 was dependent on staff for bathing and required substantial or maximal assistance from staff with toileting and hygiene. Interview and observation on 11/27/23 at 9:05 A.M. revealed Resident #12 was sitting in a wheelchair with a towel covering her head and a short-sleeved shirt.…

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

Based on observation, and staff interview the facility failed to maintain a safe comfortable environment when the ceiling was missing tiles by the nursing station. This had the potential to affect all 42 Residents in the facility. Findings include: Observation on 08/02/23 at 2:00 P.M. revealed the front hall ceiling was missing approximately 16 tiles above the nurses station. Interview on 08/02/23 at 2:15 P.M. with Regional Maintenance Director #15 verified the front hall ceiling was missing approximately 16 tiles above the nurses station. This deficiency represents noncompliance investigated under Complaint Number OH00144785.

Based on staff interview, document review, and observation the facility failed to have a safe homelike environment when they failed to have properly functioning hot water in the back part of the building. This affected 18 residents living in rooms 27-46 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). The facility census was 42. Findings include: Observation on 08/02/23 at 11:05 A.M. revealed there was no hot water in the resident shower room on the back hall. Interview on 08/02/23 at 11:07 A.M. with State Tested Nurse Aide (STNA) #10 verified there was no hot water on the back hall in the resident rooms or in the shower room. STNA #10 stated the water has been out for a month. Interview with a confidential resident on 08/02/23 at 11:10 A.M. revealed the resident stated they did not want their name used but there is no hot water in part of the building. Interview with a confidential resident on 08/02/23 at 1:15 P.M. revealed the resident did not want her name used, but they do not have hot water in their room. Interview on 08/02/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the resident fund accounts, staff interviews and policy review, the facility failed to timely close one discharged resident's (#93) fund account. This affected one (#93) of five resident personal funds accounts reviewed. The census was 33. Findings include: Review of the resident funds for discharged residents revealed Resident #93 expired on [DATE]. Review of Resident #93's personal funds account. revealed the account was not closed and had a current balance of 490.02 dollars with a Medicaid payer. Interview with Business Office Manager (BOM) #75 and the Administrator on [DATE] at 2:05 P.M., verified the 490.02 dollars in Resident #93's fund account was not sent to Medicaid state recovery. Resident #93 was the only expired resident with an account the past year. At that time, the Administrator added they were not successful when they attempted to find the resident's family after his death six months ago. Review of the policy titled Patient Resident Trust Fund Policy dated 05/2018, 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 and staff interview, the facility failed to notify the state mental health authority of a change in resident's mental health status. This affected one (#22) of one resident reviewed for Pre-admission Screening and Resident Review (PASARR) during the annual survey. The facility census was 33. Findings include: Review of Resident #22's PASARR dated 07/25/18 was silent in section D indicating Resident #22 did not have any indications of serious mental illness. Review of Resident #22's medical record revealed an admission date of 07/26/18. Diagnoses included but were not limited to the following: cerebral infarction, acute and post procedural respiratory failure, left hand contracture, left elbow contracture, difficulty in walking, cognitive communication deficit, major depressive disorder, and unspecified psychosis. Review of Resident #22's psychiatric follow up evaluation, dated 04/22/21, revealed Resident #22 had a history of depression, psychosis, sexually inappropriate behaviors, and personality disorder. The notes indicated Resident #22's issues…

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, staff interview, record review, and policy review, the facility failed to include residents and/or their representatives in care planning meetings and conduct quarterly care plan meetings. This affected three (#3, #8, and #29)of four residents reviewed for Care Planning during the annual survey. The facility census was 33. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 03/19/18, with diagnoses including: Alzheimer's disease, cognitive communication deficit, muscle weakness, dysphagia, Post-Traumatic Stress Disorder, Hypertension, Acute necrotizing hemorrhagic encephalopathy, and altered mental status. Review of Resident #8's medical record was silent for Care Conference notes. Review of Resident #8's profile contained three contacts with phone numbers, two of which were designated as a Care Conference Person. Interview with Registered Nurse (RN) #550 on 04/20/22 at 11:31 A.M., revealed no evidence of Care Conference for Resident #8 for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure the medication error rate was less than five percent. The facility had two errors of 27 opportunities resulting in a 7.41% error rate. This affected one (#36) of six residents observed during medication pass. The facility census was 33. Findings include: Review of the medical record revealed Resident #36 admitted on [DATE], with diagnoses of right lower limb cellulitis, mild primary open-angle glaucoma, age-related bilateral nuclear cataract, type II diabetes, and Stage III chronic kidney disease. Review of Resident #36's physician orders for Latanoprost Solution 0.005% instill one drop in both eyes at bedtime and Timolol Maleate Solution 0.5% instill one drop in both eyes at bedtime related to primary open-angle bilateral mild stage glaucoma. Observation on 04/18/22 at 9:05 P.M., Licensed Practical Nurse (LPN) #140, looked in the medication cart and medication room but did not locate Resident #36's Latanoprost or Timolol eye…

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, physician and staff interviews, the facility failed to timely notify the physician of critical lab results. This affected one (#25) of three residents reviewed for hospitalization. The facility census was 33. Findings include: Review of the medical record of Resident #25 revealed an admission date of 01/20/22. Diagnoses included breast cancer, acute kidney failure, constipation, major depressive disorder, history of COVID-19, paroxysmal atrial fibrillation, morbid obesity, anemia, history of displaced intertrochanteric fracture of right femur, hyperlipidemia, congestive heart failure, seizures, cerebral aneurysm, and essential hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/22/22, revealed the resident had moderately impaired cognition. The resident did not exhibit any behaviors during the assessment period. The resident was dependent on two staff for bed mobility, transfers, and toileting and extensive assistance of one staff for eating. Review of a progress note dated 02/21/22 at 8:35 A.M., Resident #25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, menu review, resident and staff interviews, the facility failed to provide meal preferences for residents and failed to follow prepared menus for the residents. This affected one (#8) of two residents reviewed for food preferences. The facility failed to update the menus when substituting equally nutritious food and notifying residents of the changes. This affected all 33 of 33 residents who received meals form the kitchen. The facility census was 33. Findings include: 1. Review of the medical record revealed Resident #8 was admitted [DATE], with diagnoses including: adult failure to thrive, anemia hereditary and idiopathic neuropathy, nausea with vomiting unspecified, cough, osteo arthritis of knee, diabetes mellitus without complications, difficulty in walking, muscle weakness, heart failure and chronic obstructive pulmonary disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition for decisions.…

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

Based on observation, staff interview, review of manufacture's instructions and facility policy, the facility failed to ensure the medication error rate was less than five percent. The facility had a an error rate of two of 27 opportunities resulting in a 7.41%. This affected one (#29) of six residents observed during medication pass. The facility census was 33. Findings include: Record review for Resident #29 revealed an admission date of 03/07/19, with diagnoses including: acquired absence of right leg above knee, muscle weakness, anxiety, depression, type two diabetes, and peripheral vascular disease. Review of Resident #29's physician orders revealed an order for Humalog (fast acting insulin) 100 unit / milliliter (ml) per sliding scale subcutaneous with meals related to type two diabetes. a. Observation on 04/16/19 at 4:56 P.M., with Licensed Practical Nurse (LPN) #37, during medication administration revealed LPN #37 to obtain a Humalog Kwik pen labeled 100 unit / ml. LPN #37 visually viewed the liquid in the Humalog Kwik pen, applied a new needle, then proceeded to dial to 10…

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

Based on observation, staff interview, review of manufacture's instructions and facility policy, the facility failed ensure a resident was free from a significant medication error by not priming an insulin pen prior to preparing ordered dose. This affected one (#29) of six residents observed during medication pass. The facility identified two residents (#29 and #181) who used insulin pens. The facility census was 33. Findings include: Record review for Resident #29 revealed an admission date of 03/07/19, with diagnoses including: acquired absence of right leg above knee, muscle weakness, anxiety, depression, type two diabetes, and peripheral vascular disease. Review of Resident #29's physician orders revealed an order for Humalog (fast acting insulin) 100 unit / milliliter (ml) per sliding scale subcutaneous with meals related to type two diabetes. a. Observation on 04/16/19 at 4:56 P.M., with Licensed Practical Nurse (LPN) #37, during medication administration revealed LPN #37 to obtain a Humalog Kwik pen labeled 100 unit / ml. LPN #37 visually viewed the liquid in the Humalog Kwik…

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.