Canfield Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, observation and facility policy review, the facility failed to ensure Resident #25 were free from staff-to-resident verbal abuse. This affected one (Resident #25) or two residents reviewed for abuse. The facility census was 72. Findings include:Review of the medical record revealed Resident #25 was admitted on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder (MDD), anxiety, hypertension, and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. She required set up assistance with eating, substantial assistance with oral hygiene, toileting hygiene, dressing, personal hygiene and bed mobility. Resident #25 was dependent on staff for showers. Review of the care plan dated 07/31/25 revealed Resident #25 had impaired cognition related to intellectual disability and cognitive communication deficit. Interventions included staff were 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 record review, staff interview, review of the shower audit tool and facility policy review, the facility failed to ensure Resident #6 received showers as scheduled. This affected one (Resident #6) of one resident reviewed for activities of daily living (ADL). The facility census was 72. Findings include:Record review revealed Resident #6 was admitted on [DATE] with diagnoses of immobility syndrome, severe protein-calorie malnutrition, and extended spectrum beta lactamase (ESBL) resistance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was dependent on staff for toileting hygiene, showers, dressing, and transfers. Resident #6 was cognitively intact. Review of Resident #6's current care plan revealed Resident #6 had an ADL self-care performance deficit and required the staff to do all of the effort or have two or more staff to assist. Interview on 08/25/25 at 11:08 A.M. with Resident #6 revealed she was not bathed regularly and at times went one to two…

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, interview, and facility policy review, the facility failed to ensure residents were provided with one-on-one activities to meet their interests and needs. This affected three (Residents #25, #29, and #83) of three residents reviewed for activities. The facility census was 72. Findings include:1. Review of Resident #25's medical record revealed an admission date of 06/09/25 with diagnoses included schizoaffective disorder, major depressive disorder (MDD), anxiety, hypertension, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had impaired cognition and required setup assistance with eating, substantial assistance for oral hygiene, toileting, dressing, personal hygiene, and bed mobility, and finally Resident #25 was dependent on staff for showers. Review of the care plan dated 07/31/25 revealed Resident #25 was alert and oriented and could make her needs known. She continued to sleep a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, the facility failed to ensure Resident #83's emergency contact was notified of a change in condition. This affected one (Resident #83) out of three residents reviewed for notification of change in condition. The facility census was 72. Findings include:Review of Resident #83's closed medical record revealed an admission date of 01/07/18 and a discharge date of 06/26/25. Diagnoses included ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, major depressive disorder (MDD), and need for assistance with Activities of Daily Living (ADL) and personal care. Review of Resident #83's emergency contacts revealed the resident's father was listed as emergency contact #1; however, throughout the investigation it was identified the resident's father passed away in November of 2022. Resident #83's brother was listed as emergency contact #2. Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #83…

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 interview, the facility failed to ensure physician visits were provided in accordance with regulations for two (Residents #72 and #74) of three residents reviewed for physician visits. The facility census was 72. Findings include:1. Review of Resident #72's medical record revealed an admission date of 06/25/25. Diagnoses included rhabdomyolysis, chronic obstructive pulmonary disease, depression, hypertension, gout, adult failure to thrive, chest pain, and insomnia. The physician and nurse practitioner documented entries for visits on 06/26/25. There was no further evidence of physician visits as of 09/09/25. On 09/09/25 at 1:57 P.M., Regional Registered Nurse (RN) #896 verified she was only able to locate evidence of Resident #72 being visited by the physician on 06/25/25. All other visits were made by the nurse practitioner. 2. Review of Resident #74's medical record revealed an admission date of 06/10/25. Diagnoses included type two diabetes mellitus, hypertension, peripheral vascular disease, major depressive disorder, hyperlipidemia, anemia,…

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 medication information, and interview, the facility failed to ensure adequate monitoring of laboratory values to determine if medications were within recommended therapeutic range. This affected one (Resident #2) of five residents reviewed for medication use. The facility census was 72. Findings include:Review of Resident #2's medical record revealed diagnoses including bipolar disorder, generalized anxiety disorder, chronic respiratory failure and chronic obstructive pulmonary disease. Divalproex sodium delayed release (Depakote) (anti-convulsant) 250 milligrams (mg) every morning and bedtime for bipolar disorder was ordered on 01/23/24. There was no evidence of a Depakote level being obtained since initiation of the Depakote. During an interview on 09/03/25 at 9:33 A.M., Certified Nurse Practitioner (CNP) #889 stated she started in July 2025 and was unaware Resident #2 had not received a Depakote level and she would order one. Review of Medscape information regarding Depakote revealed valproic acid level range was 50-100 micrograms per…

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 interview, the facility failed to arrange for outside services with an orthopedic doctor in a timely manner. This affected one (Resident #5) of 12 residents reviewed for accidents and follow up actions taken related to accidents. The facility census was 72. Findings include:Review of Resident #5's medical record revealed diagnoses including left sided weakness and paralysis following a stroke, chronic obstructive pulmonary disease, generalized muscle weakness, cognitive communication deficit, major depressive disorder, atrial fibrillation, heart disease, stage three chronic kidney disease and viral hepatitis C. A nursing note dated 06/10/25 at 1:40 A.M. indicated Resident #5 was found on the bathroom floor in which he sustained a skin tear to the left hand knuckles. Resident #5 stated he was trying to go to the bathroom. A note dated 06/10/25 at 3:12 P.M. indicated Resident #5 had fallen and had new left hand swelling. X-ray results were pending. A Nurse Practitioner note dated 06/12/25 revealed x-ray results were reviewed, and Resident #5 would be…

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, medical record review and interview, the facility failed to maintain furniture in proper working order. This affected four (Residents #17, #36, #46 and #82) of 72 residents whose environment was screened for safety, functionality and comfort. The facility census was 72. Findings include:1. On 08/26/25 at 1:03 P.M., two drawers of the built-in dresser in room [ROOM NUMBER] were missing and/or broken. Resident #17 and #46 resided in the room. Resident #17 indicated he was admitted after Resident #46 and suggested he might have more information as to how long the drawers were broken. Resident #46 stated one of the drawer fronts had recently broken but was unwilling to provide a time frame. The other had been broken since before he was admitted . The bottom left drawer was also off track and difficult to access. Review of Resident #46's medical record revealed an admission date of 06/13/24. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety order and generalized muscle…

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, policy review and interview, the facility failed to ensure Resident #65's written discharge summary was accurate to reflect the amount of the medication, Oxycodone, provided to the resident at the time of discharge. This affected one resident (#65) of three residents reviewed for discharge. The facility census was 64. Findings include: Review of the closed medical record for Resident #65 revealed an admission date of 02/29/24 and a discharge date of 02/26/25. Resident #65 had diagnoses including paraplegia, chronic pain syndrome, and major depression. Review of a care plan dated 02/29/24 revealed Resident #65 had chronic complaints of pain. Interventions included to provide medications as ordered and monitor for effectiveness. Review of a physician order dated 01/07/25 revealed an order for the controlled substance Oxycodone 20 milligrams (mg) (opioid pain medication) by mouth four times a day. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure an allegation of physical abuse was thoroughly investigated. This affected one resident (#70) of three residents reviewed for abuse. The facility census was 62. Findings include: Review of the medical record for Resident #70, revealed an admission date of 09/30/22. Diagnoses included peripheral neuropathy, repeated falls, presence of other orthopedic joint implants, alcohol dependence, psychoactive substance abuse, cocaine use, vascular dementia, unspecified mood disorder, and schizophrenia. Resident #70 was discharged back to the community on 11/23/23. Review of Resident #70's comprehensive admission Minimum Data Set (MDS) 3.0 assessment, dated 09/12/23, revealed the resident had a Brief Inventory Mental Status (BIMS) score of 15 out of 15 indicating he had intact cognition and no memory impairment. The resident was independent or required supervision for Activities of Daily Living (ADLs) including bed mobility, transfers, ambulation. Review of…

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

Based on record review and staff interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 66 residents residing in the facility. Findings include: Review of schedules and punch detail for Registered Nurses from 09/01/23 to 09/24/23 revealed there was no RN coverage for eight consecutive hours on 09/02/23, 09/03/23, 09/04/23, 09/16/23, 09/17/23, and 09/23/23 as required. Interview on 09/25/23 at 10:56 A.M. with the Director of Nursing (DON) revealed one of the registered nurses, who had been out on maternity leave, just came back to work the previous week. Interview on 09/26/23 at 12:52 P.M. with the Administrator confirmed the facility had not had eight-hour consecutive RN coverage on a daily basis on the dates reviewed above. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146473

Based on observation, interview, and review of facility policy, the facility failed to serve palatable meals. This affected 65 residents who received meals from the kitchen. The facility identified Resident #22 as receiving noting by mouth. The facility census was 66. Findings include: Interview on 09/18/23 at 10:56 A.M. with Resident #19 revealed no hot plates were ever used, and the food was cold. Observation of the tray line on 09/21/23 from 11:55 A.M. to 12:10 P.M. revealed no concerns with food quality. Observation was made as dietary staff prepared the lunch meal that consisted of chicken tacos, rice, corn, and watermelon. Cooking temperatures obtained at this time by Culinary Director #856 using a facility thermometer, confirmed the food being served reached temperatures that assured food safety. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the Wing One food cart. Observation was made as the test tray was prepared, placed on…

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

Based on observation, interview and facility policy. The facility failed to ensure the dietary staff members wore appropriate hair covering and failed to ensure the kitchen was clean and sanitary. This affected 65 resident who received meals from the kitchen, the facility identified Resident #22 as receiving nothing by mouth. The facility census was 66. Findings include: Observation of the kitchen on 09/18/23 from 8:06 A.M. to 8:31 A.M. with Dietary [NAME] #707 revealed the following concerns: Culinary Aide #711 was observed on tray line not wearing a proper hair covering. At the time of observation, Culinary Aide #711 confirmed she did not have a hair covering on but had one on earlier in the day. Observation of the three-door reach in freezer located in the dry storage area revealed the bottom of the unit had an accumulation of food debris which included 16 loose peas, one corn kernel and two pieces of diced carrot. Observation of the two-door reach in freezer located in the dry storage area revealed the bottom of the unit an accumulation of food debris around the edges.…

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

Based on record review and interview the facility failed to have the required participants at the Quality Assurance Performance Improvement ( QAPI) meeting. This had the potential to affect all 66 residents. The facility census was 66. Findings include: Review of Policy and Standards Procedures Quality Assurance Performance Improvement ( QAPI) Plan #NS 1024-00 revealed the QAPI committee will include the Executive Director, Director of Nursing, Medical Director, Infection Preventionist, three other staff members and other state required attendees. Review of QAPI meeting agendas dated 09/02/22, 10/04/22, 11/02/22, 12/02/22, 01/06/23, 02/07/23, 03/03/23, 04/16/23, 05/04/23, 06/08/23, 07/05/23, 08/03/23, 09/01/23, the Executive Director, Director of Nursing, Infection Preventionist #706, and Medical Director attended all the meetings but thirteen of thirteen meetings did not have other staff members attend to meet the required attendance of the committee. Interview on 09/26/23 at 3:26 P.M. the Administrator verified no documented evidence other staff members attended the meeting dates.

Based on observation , record review, review of medication information, policy review and interview the facility failed to store medication appropriately. Improper storage was identified on two (Unit II medication cart and Unit I medication room) of three storage units observed. This affected four residents, Resident #12, #24, #57, and #261 of 66 residents residing in the facility. Findings include: 1. On 09/20/23 between 11:30 A.M. and 11:38 A.M., Licensed Practical Nurse (LPN) #732 was observed monitoring Resident #24's blood glucose level and administering insulin. While preparing to administer Resident #24's Humalog via an opened insulin pen, it was noted there was no date indicating when the insulin pen was opened. The label indicated the Humalog pen was delivered 08/22/23. This was verified by LPN #732 at the time of observation. Review of the Medscape website revealed opened Humalog pens could be stored at room temperature up to 28 days. 2. Observations of the 100 hall (Unit I) medication room with LPN #725 on 09/26/23 at 10:38 A.M. revealed there were two refrigerators 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 record review and interview, the facility failed to ensure a staff member did not verbally abuse Resident #57. This affected one resident (#57) out of five residents reviewed for abuse. The facility census was 66. Findings include: Review of the medical record for Resident #57 revealed an admission date of 07/21/23 with diagnoses including opioid abuse, anxiety disorder, post-traumatic stress disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact, exhibited no behaviors or rejection of care, and required supervision with no setup for walking or locomotion. Review of Resident #57's care plan initiated 08/02/23 revealed Resident #57 had a diagnosis of depression, anxiety and post-traumatic stress disorder, and had a history of opioid abuse with a goal Resident #57 would not experience any increase in signs or symptoms of mood disturbance. Interventions included administer medications as ordered, behavioral health…

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

Based on record review and interview, the facility failed to complete level two Preadmission Screening and Resident Review ( PASRR) for Resident #42's new diagnosis of schizoaffective disorder. This affected one (Resident #42) of two residents reviewed for PASRR. The facility census was 66. Findings include: Review of medical record for Resident #42 revealed an admission date of 05/26/21. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia with other behavioral disturbance, adult failure to thrive, solitary pulmonary (lung) nodule, cognitive communication deficit, type two diabetes without complications, anxiety disorder, prostate cancer, and post-traumatic stress disorder (PTSD). On 06/28/22 a new diagnosis of schizoaffective disorder was added to Resident #42's diagnoses. Review of the 09/08/23 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #42 was severely impaired cognitively, exhibited no hallucinations or delusions but did exhibit physical and verbal behaviors one to three days during the assessment reference period, required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #48 was provided an opportunity to give input into her plan of care. This effected one resident (Resident #48) of two residents reviewed for care planning. The facility census was 66. Findings include: Review of Resident #48's medical record revealed diagnoses including schizoaffective disorder, depression, anxiety disorder, and cognitive communication deficit. An admission assessment dated [DATE] indicated Resident #48 participated in the 48 hour baseline care planning. A social service note dated 08/30/22 at 7:32 P.M. indicated a call was placed to Resident #48's brother to schedule a care conference meeting. A voice message was left for a return call. A social service note dated 08/31/22 at 4:00 P.M. indicated a call was placed to Resident #48's brother. A care conference via phone was scheduled for 09/07/22 at 11:00 A.M. A social service note dated 08/31/22 at 4:09 P.M. indicated Resident #48's son was notified of the 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 medical record review and interview, the facility failed to initiate a dressing and grooming restorative program for one resident, Resident #48, of twenty five residents screened for activities of daily living. The facility census was 66. Findings include: Review of Resident #48's medical record revealed diagnoses including schizoaffective disorder, depression, anxiety disorder, hypertension, obesity, difficulty in walking, generalized muscle weakness and osteoporosis. An annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was moderately cognitively impaired. Extensive assistance was required with bed mobility, dressing, and personal hygiene. Review of an Occupational Therapy (OT) evaluation dated 07/20/23 indicated Resident #48 had been referred to OT after a recent decline in activities of daily living and weakness. An OT Discharge summary dated [DATE] indicated at the time of discharge from OT, Resident #48 required stand by assistance for hygiene and grooming tasks 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 medical record review and interview, the facility failed to initiate a Range of Motion (ROM)Restorative Nursing Program (RNP) for one resident , Resident #40, of twenty residents screened for range of motion. The facility census was 66. Findings include: Review of Resident #40's medical record revealed diagnoses including flaccid hemiplegia (one side of the body loses motor function and becomes weak or paralyzed) affecting the left non-dominant side, stroke and generalized muscle weakness. Review of a Physical Therapy (PT) evaluation dated 08/17/23 revealed Resident #40 had limitations in ROM. A Discharge summary dated [DATE] indicated recommendations for a RNP for transfers and range of motion. During an interview on 09/18/23 at 11:20 A.M., Resident #40 stated she was unable to voluntarily move her left side. Resident #40 used her right arm and moved her left arm stating she was able to do ROM to her left arm. However, she was unable to move her left leg and ROM was not provided. On 09/20/23 at 2:00…

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, observations and interviews, the facility failed to eliminate hazard risk when a cognitively and physically impaired resident with fall risk was able to leave the secured courtyard smoking area due to an unsecured gate. This affected one resident ( Resident #31) of eight residents reviewed for accidents/hazards. The facility census was 66. Findings include: Review of medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnosis included malignant neoplasm of unspecified part of bronchus or lung and brain, secondary malignant neoplasm of unspecified lung, cachexia, unspecified protein calorie malnutrition, muscle weakness, need for assistance for personal care, lack of coordination, adult failure to thrive, alcohol abuse. A niece was listed as resident representative durable power of attorney for care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 could make himself understood, was able to understand others, 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 policy review, interview, review of an article from the American Journal of Health-System Pharmacy, and observation, the facility failed to ensure staff appropriately flushed a feeding tube during medication administration . This effected one (Resident #22) of one resident reviewed for medication administration via feeding tube. Findings include: On 09/20/23 between 11:06 A.M. and 11:15 A.M., Licensed Practical Nurse #732 was observed administering medication to Resident #22 via a feeding tube. Among the medications administered were famotidine (a gastric acid secretion reducer), allopurinol (helps prevent increase or decreases uric acid levels), provera (hormone), sertraline (antidepressant), cimetidine (gastric acid secretion reducer) and cod liver oil (liquid). All the pills were crushed. Approximately five milliliters (ml) of water were added to the cups with the medications before they were emptied into the feeding tube. No flushes with water were conducted between the medications. On 09/20/23 at 11:29 A.M., LPN #732 verified although she flushed the feeding tube…

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, facility policy review and interview the facility failed to ensure Resident #29's medication regimen was free of unnecessary medication. The facility failed to ensure a psychotropic medication was discontinued timely following a pharmacy recommendation and nurse practitioner approval. This affected one resident (#29) of five residents reviewed for unnecessary medication. The facility census was 66. Findings include: Medical record review revealed Resident #29's initial admission to the facility was 06/30/23. Diagnoses included infection of the skin and subcutaneous tissue, unspecified severe protein calorie malnutrition, ulcer of sacral region unspecified stage, paraplegia, neuromuscular dysfunction of bladder, anxiety disorder, depression, muscle weakness, psychoactive substance abuse, opioid dependence, unspecified mood affective disorder, Viral Hepatitis C, asymptomatic Human Immunodeficiency Virus infection status. Review of the Comprehensive Minimum Data Set Assessment ( MDS) 3.0 dated 07/11/23, revealed the resident's cognition was intact. Review of…

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

Based on medical record review and interview, the facility failed to obtain laboratory tests as ordered. This affected one resident (#43) of five residents reviewed for unnecessary medication. The facility census was 66. Findings include: Review of Resident #43's medical record revealed diagnoses including type two diabetes mellitus with diabetic peripheral angiopathy, cerebrovascular disease, end stage renal disease, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, hypercholesterolemia, anemia, and fatty liver. A progress note by a Certified Nurse Practitioner (CNP) dated 09/05/23 indicated Resident #43's chief complaint was increased fatigue. No recent labs were available for review. Orders were written for laboratory tests including a Complete Blood Count (CBC) with differential and Comprehensive Metabolic Panel (CMP) every week for four weeks. Laboratory results from 09/07/23 revealed abnormal CBC results including an elevated [NAME] Blood Count (WBC) of 11.58 (reference range 4.8-10.8) and elevated platelet account of 440 (reference range of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide routine dental services for Resident #39 and Resident #15. This affected two residents (#15 and #39) of 25 residents screened for dental services. The facility census was 66. Findings include: 1. Resident #39 was admitted to the facility on [DATE] with diagnosis of major depressive disorder, alcohol dependence, anxiety disorder, Post-traumatic stress disorder, very low level of personal hygiene, personal history of suicidal behavior, severe protein calorie malnutrition, severe obesity due to excess calories, alcoholic hepatitis without ascites, personality disorder, urinary incontinence, incontinence of feces, atrial fibrillation, cognitive communication deficit, need for assistance with personal care, hypertension, disorder of teeth and supporting structures. The resident had a Managed Medicaid Non-PPS insurance. An encounter note written by Nurse Practitioner (NP) #810 date of service 07/13/23 revealed an acuity visit was done 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 record review and interview, the facility failed to ensure treatments were documented in the medical record as completed for Resident #43. This affected one resident (#43) of the 31 resident records reviewed for the annual survey. The facility census was 66. Findings include: 1. Review of Resident #43's medical record revealed diagnoses including colostomy status. a. Review of physician orders revealed an order dated 09/12/23 for application of no sting skin prep around the stoma and to red areas when changing the colostomy bag every shift and an order dated 06/27/23 to change the ostomy bag four times a month. Review of the September 2023 Treatment Administration Record (TAR) revealed staff were not documenting when the colostomy bag was changed. On 09/25/23 at 1:24 P.M., interview of Licensed Practical Nurse (LPN) #706 verified the order for skin prep around the ostomy was a FYI (for your information) order so staff were aware to apply it when colostomy care was provided and was reflecting ostomy 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 observation, interview and policy review the facility failed to ensure adequate infection control measures were implemented during trach care, pressure ulcer bandage changes, and use of the urinary catheter. This affected two residents (#22 and #43). The census was 66. Findings include: 1. On 09/20/23 between 11:15 A.M. to 11:21 A.M., Licensed Practical Nurse (LPN) #732 was observed providing trach care and tracheal suctioning for Resident #22. Clean gloves were applied. LPN #732 opened a sterile package which contained a suction catheter and a pair of sterile gloves. The suction catheter was attached to tubing from the suction machine. The suction catheter was removed from the package with the clean gloves instead of using sterile gloves. The section of the catheter being inserted into the trach was handled with the clean glove. The suction catheter was removed with the end wiped with a tissue then reinserted into the trach. When preparing to change the trach inner cannula shiley, a new set of clean…

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 infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all antibiotics were appropriate for treatment. This had the potential to affect all 78 residents residing in the facility. Findings include: Review of the infection control log dated 01/2021 to 09/2021 revealed there was no evidence August 2021 and September 2021 infections were logged, trended, and checked to ensure antibiotics met criteria for treatment. Review of the log revealed in January 2021 there were two urinary tract infections (UTI) and only one had a culture with an organism listed. There was also one wound infection, one tooth infection, and one eye infection, however the infections were not noted on the map for trending. The map did not include the organism only the site of the infections. All the infections were treated with antibiotics, however only one antibiotic was checked to ensure the resident met criteria for antibiotic treatment. Review of the log for February 2021 there were three wound infections, four UTI's, and one eye infections. There…

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 infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all antibiotics were appropriate for treatment. This had the potential to affect all 78 residents residing in the facility. Findings include: Review of the infection control log dated 01/2021 to 09/2021 revealed there was no evidence August 2021 and September 2021 infections were logged, trended, and checked to ensure antibiotics met criteria for treatment. Further review of log revealed in January 2021 there was two urinary tract infection (UTI) and only one had a culture with an organism listed. There was also one wound infection, one tooth infection, and one eye infection, however the infections were not noted on the map for trending. The map did not include the organism only the site of the infections. All the infections were treated with antibiotics, however only one antibiotic was checked to ensure the resident met criteria for antibiotic treatment. The log for February 2021 there was three wound infections, four UTI's, and one eye infections. There was only…

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 an injury report, interview and policy review, the facility failed to ensure a physician and responsible party received timely notification of an accident involving one (Resident #338) and one (Resident #339) and/or responsible party were timely notified of a room change. This affected two (Resident's #338 and #339) of two residents reviewed for notification. The census was 78. Findings include: 1. Review of Resident #338's closed medical record revealed diagnoses including Alzheimer's disease, dementia, anxiety disorder, diabetes mellitus, and acquired absence of the left below the knee amputation. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #338 was severely cognitively impaired and required supervision for locomotion on and off the unit. A Nurse Practitioner progress note dated 09/15/20 at 5:32 P.M. indicated Resident #338 had an appointment at the podiatrist who wanted to send her to the emergency department to evaluate her toe for blood…

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

Based on medical record review, review of personnel files, review of facility reported incidents, review of the facility's Abuse policy, review of the employee handbook and interview, the facility failed to ensure staff did not misappropriate resident property. This affected one (Resident #340) of five residents reviewed for misappropriation. The facility census was 78. Findings include: Review of Temporary Nurse Aide #121's personnel file revealed she was hired 01/27/20 as a hospitality aide. The employee became a Temporary Nurse Aide on 09/18/20. The personnel file contained a statement from Business Office Manager #3 which indicated on 11/10/20, Counselor #122 reported Temporary Nurse Aide #121 asked Resident #340 for money (and received money) on several occasions. Temporary Nurse Aide #121 promised to repay Resident #340 on pay day. Temporary Nurse Aide #121 would not repay the money. A statement by Licensed Practical Nurse (LPN) #19 dated 11/14/20 indicated Resident #340 indicated Temporary Nurse Aide #121 had borrowed from her more than once but never repaid the last $25 she…

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

Based on medical record review, review of personnel files, review of facility reported incidents, review of the facility's Abuse policy, review of the employee handbook and interview, the facility failed to ensure allegations of a staff potentially misappropriating a resident's property were reported to the State Agency. This affected one (Resident #340) of five residents reviewed for misappropriation. The facility census was 78. Findings include: Review of Temporary Nurse Aide #121's personnel file revealed she was hired 01/27/20 as a hospitality aide. The employee became a Temporary Nurse Aide on 09/18/20. The personnel file contained a statement from Business Office Manager #3 which indicated on 11/10/20 Counselor #122 reported Temporary Nurse Aide #121 asked Resident #340 for money (and received money) on several occasions. Temporary Nurse Aide #121 promised to repay Resident #340 on pay day. Temporary Nurse Aide #121 would not repay the money. A statement by Licensed Practical Nurse (LPN) #19 dated 11/14/20 indicated Resident #340 indicated Temporary Nurse Aide #121 borrowed…

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

Based on medical record review and staff interview, the facility failed to ensure treatments for a wound were implemented in a timely manner. This affected one (Resident #339) of two residents reviewed for non-pressure related skin impairment. The facility census was 78. Findings include: Review of Resident #339's medical record indicated an admission date of 06/12/20. Diagnoses included complications of gastric band procedure and anoxic brain damage. Hospital discharge instructions revealed instruction to continue to change midline wound dressing daily. A collagen dressing was to be changed daily and covered with dry gauze. A hand-written nurse to nurse report indicated Resident #339 had a midline incision from an old surgery which had healed but had two open areas. Review of the admission assessment indicated Resident #339 had a surgical incision on the abdomen (no indication of a size or appearance) and a rash. The assessment indicated there was not a treatment order in place for each area noted. There was no documented evidence the physician was contacted for a treatment order…

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, interviews, observation and policy review, the facility failed to ensure restorative therapy was performed per the resident's physician's orders and plan of care. This affected two (Resident's #12 and #339) of four reviewed for activities of daily living (ADL). The facility census was 78. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), quadriplegia, spondylolysis, and radiculopathy of lumbar and cervical region. Interview on 09/13/21 at 11:20 A.M., with Resident #12 revealed she had MS and spinal cord injuries that have left her a quadriplegic. The resident reported her bilateral hand contractures and knee (leg) contractures had worsen and she could not raise her arms as far as she could after receiving therapy months ago. The resident confirmed she has not received restorative therapy since she had completed therapy months ago. She stated she only received therapy for approximately two…

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 facility smoking list, observation, interview, and policy review the facility failed to ensure residents were provided adequate supervision while smoking and failed to ensure accurate comprehensive smoking assessments were completed. This affected two (Resident #12 and #62) of four reviewed for accidents. The facility census was 78. Findings included: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including cigarette nicotine dependence, multiple sclerosis (MS), quadriplegia, spondylolysis, and radiculopathy of lumbar and cervical region. Review of the facility smoking list dated 09/01/21 revealed Resident #12 was listed as supervision with and a smoking apron. Review of Resident #12's smoking assessment dated [DATE] revealed the resident had dexterity problems, smoked six to 10 times daily, could light her own cigarette, required a cigarette holder, and could dispose of a cigarette appropriately. The assessment did not…

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 policy review, the facility failed to ensure Resident #334 received diet ordered by the physician. This affected one (Resident #334) of seven residents reviewed for nutrition. The facility census was 78. Findings include: Record review revealed Resident #334 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, alcohol dependence, vitamin B deficiency, anemia, and chronic peptic ulcer disease. Interview with Resident #334 on 09/14/21 at 8:22 A.M. revealed he was not getting double portion of meals as ordered. The resident reported he had been using his own money to buy snacks. Review of the facility's list of resident diets dated 09/14/21 revealed no evidence Resident #334 was to receive double portion with meals. Review of Resident #334 diet requisition form dated 08/23/21 revealed no evidence of double portions with meals. Review of Resident #334's admission orders from another…

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 interviews, record reviews and policy review, the facility failed to ensure Seroquel (antipsychotic) was prescribed appropriately for Resident #34 who had no approved diagnoses for the antipsychotic medication. This effected one (Resident #34) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: Review of the medical records for Resident #34 revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, Parkinson's disease, metabolic encephalopathy, dementia without behavioral disturbances, kidney failure, and bipolar disorder added to diagnoses list on 09/15/21. Review of the September 2021 physician's orders revealed Resident #34 was ordered Seroquel (antipsychotic) 50 milligrams (mg) by mouth at bedtime for antipsychotic, Carbidopa- Levodopa (anti-Parkinson's agent), Mirapex (anti-Parkinson's agent), Jentadueto (diabetes medication), monitoring for antipsychotic medication side effects and adverse…

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 policy review the facility failed to ensure dental consents were signed in a timely manner. This affected one (Resident #67) of one resident reviewed for dental services. The facility census was 78. Findings include: Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including significant weight loss, heart disease, diabetes, and moderate protein-calorie malnutrition. The resident had Medicaid insurance. Interview and observation on 09/13/21 at 10:49 A.M., with Resident #67 revealed the resident was noted to be edentulous (no teeth). The resident reported she was supposed to get dentures a few months ago but never heard back from the anyone, and she would really like to get dentures. The dentist had already fitted her for the dentures. Review of Resident #67's dental notes dated 07/02/21 revealed the resident requested new dentures, and she was edentulous. Review of Resident #67's annual Minimum Data Set…

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.