Altercare Zanesville Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to maintain infection control practices during incontinence care and failed to ensure staff wore face masks during a COVID-19 outbreak. This affected one resident (#70) of two residents observed for incontinence care and had the potential to affect 31 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) residing on Unit 1 during the COVID-19 outbreak. The census was 91. Findings include: 1. On 09/19/24 at 4:58 A.M., observation of the facility front entrance door revealed a sign indicating the facility was currently under a COVID-19 Outbreak and masks should be worn. A box of face masks was available to use at the receptionist window. On 09/19/24 at 5:05 A.M., observation of Unit 1 revealed two licensed practical nurses (LPN's) (#200, #202) sitting at the nurses' desk and STNA (#203) walking down the hallway.…

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 hospital discharge orders, policy review, and interview, the facility failed to ensure special respiratory equipment was available for resident use. This affected one resident (#94) of four residents reviewed for admission rights. The facility census was 93. Findings include: Closed record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, pulmonary fibrosis, and hyperlipidemia. Review of hospital records revealed Resident #94 had been identified as having significant risk for obstructive sleep apnea and discharge orders included but were not limited to CPAP machine with adult mask and tubing while sleeping. The order stated another medication with the same name was removed, continue taking this medication and follow the directions you see here. Review of an admission minimum data set (MDS)assessment completed on 08/13/24 revealed Resident #94's cognitive status remained intact. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy and procedure review, the facility failed to ensure proper infection control techniques were followed during pressure ulcer wound care. This affected one resident (#23) of three residents reviewed for pressure ulcers. The census was 93. Findings include: Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Parkinson's Disease, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), high blood pressure and diabetes. Review of the quarterly MDS dated [DATE] revealed her cognition was intact, she had an indwelling urinary catheter and was incontinent of bowel. A Stage IV pressure ulcer was identified. Review of the Physicians orders dated 01/30/24 revealed an order to cleanse the wound with 1/4 strength Dakin's solution, pat dry, apply hydrofiber with silver, and cover with clean dry dressing once a day and when needed (PRN). On 09/09/24 at 11:05 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 observations, review of the facility meal spreadsheet, interview with staff and review of the facility policy the facility failed to ensure the residents were served the proper portion size of meat. This had potential to affect all residents receiving meals from the kitchen except for nine residents (Resident #1, #5, #14, #51, #61, #80, #81, #86 and #88) the facility had identified as nothing by mouth, mechanical soft or pureed diets. The facility census was 96. Findings included: Review the spreadsheet for 08/05/24 revealed the residents were to receive a three-ounce slice of teriyaki pork. Observation of meal service on 08/05/24 from 11:15 A.M. to 12:00 P.M. revealed the facility was serving precooked teriyaki pork however the sliced pieces for the regular texture diets (diets that were not mechanical soft or pureed) looked smaller than a three ounce portion. Dietary Coordinator #300 weighed a piece of pork and it only weighed 1.5 ounces. She verified at this time the pork was not three ounces. [NAME] #301 checked all the meal trays on the already filled Unit 3 food cart…

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 the Self-Reported Incident (SRI), interview with staff, and review of the facility policy the facility failed to prevent the misappropriation of medication for Resident #66 by facility staff. This affected one resident ( Resident #66) of three reviewed for medications. The facility census was 96. Findings included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, cerebral infarction, atrial fibrillation, polymyalgia, bipolar disorder, personality disorder, opioid disorder, generalized anxiety disorder, restless leg syndrome, Crohn's disease, malignant neoplasm of the colon, migraines, and xerosis cutis. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #66 had moderately impaired cognition. Review of the August 2024 physician orders revealed Resident #66 had an order for sumatriptan 100 milligrams as needed 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 review of the medical record and interview with the staff the facility failed to ensure a wound vacuum (vac) for Resident #58 was changed as ordered, and medications were administered in a timely manner for Resident #96. This affected one resident ( Resident #58) of three reviewed for wounds and one resident ( Resident #96) of three reviewed for medications. The facility census was 96. Findings included: 1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included acute osteomyelitis to the left ankle and foot, left foot fracture, thoracic aortic aneurysm, diabetes, right foot amputation, and Charcot [NAME] Tooth Disease. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had intact cognition. Review of the August 2024 physician's order revealed Resident #58 had an order to cleanse the left heel. Apply black foam as primary dressing, apply the wound vac at 125 millimeters of mercury (mmHg) as the outer…

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, record review, and review of the infection control logs the facility failed to maintain a comprehensive infection control log to include antibiotic use. This had the potential to affect all residents in the facility. The facility census was 84. Findings include: a. Review of Resident #27 medical record revealed an admission date of 03/31/2023. Diagnoses included cerebral infarction, muscle weakness, need for assistance with personal care, and emphysema. Continued review of the medical record revealed the resident was prescribed antibiotics in August and September 2023. Review of the Infection Control Logs for August 2023 revealed on 08/31/23 Resident #27 had a wound infection with redness, swelling, and drainage. The log indicated a culture was obtained showing Methicillin-resistant Staphylococcus aureus (MRSA). The log did not indicate what medication was prescribed, the dose of the medication, the frequency of the medication, or if the medication needed to be changed. Review of Resident #27's August and September 2023 physician orders revealed an order 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 observation, interview, and record review the facility failed to obtain written notice before relocating Resident #27 to a different room. This affected one resident (Resident #27) of one residents reviewed for room transfers. The facility census was 84. Findings include: Review of Resident #27's medical record revealed an admission date of 03/31/2023. Diagnoses included cerebral infarction, muscle weakness, need for assistance with personal care, and emphysema. Continued review revealed Resident #27 changed rooms on 01/25/24. Review of Resident #27 quarterly minimum data set assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #27 progress notes for January 2024 revealed there was no evidence the facility discussed the room change with the resident. Observation on 01/29/24 at 8:49 A.M. revealed Resident #27 was laying in bed. He was in a semi-private room and had a roommate. He utilized a trapeze to reposition himself. Interview on 01/29/24 at 8:49 A.M. with 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 interview, record review and policy review the facility failed to investigate a fall with injury and failed to complete neurological assessments after a fall with head injuries. This affected two residents (Resident #39 and #278) of four residents reviewed for falls. The census was 84. Findings include: Review of Resident #298's medical record revealed an admission date of 05/12/23 and a discharge date of 12/04/23. Diagnosis included unspecified dementia, muscle weakness, hypertension, and bipolar disorder. The medical record indicated that the resident was cognitively intact and independent for bed mobility toilet use, and transfers. Review of Residents #298's care plan for falls dated 5/15/23 revealed the resident was at risk for falls or injury related to confusion and altered mental status, history of falls, laxatives, and she is impaired. Review of the nursing progress note recorded on 12/04/23 at 4:45 A.M. by Licensed Practical Nurse (LPN) #112 revealed Resident #298 transferred to the emergency…

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 pain was addressed post-fall and pain assessments were completed post-fall per policy. This affected one resident (Resident #19) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #19 revealed an admission date of 06/17/23. Diagnoses included Alzheimer's disease with late onset, difficulty walking, fracture of superior rim left pubis, subsequent encounter fracture with routine healing, unsteady of feet and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 1 which indicated cognitively impaired. Review of fall events with injuries for Resident #19 dated 06/21/23 and 12/02/23 revealed non-verbal assessments were not completed for pain despite the resident's impaired cognition. For the fall event with injuries on 10/01/23, the resident sustained a skin tear to the left top 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 interview, record review and policy review the facility failed to maintain accurate medical records. This affected one resident (Resident #13) of one residents reviewed for fluid restrictions. The census was 84. Findings include: Review of the medical record for Resident #13 revealed an admission date of 05/03/23 with diagnoses of: chronic systolic (congestive) heart failure, chronic kidney disease, stage 3 and chronic respiratory failure with hypoxia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating cognitive intactness. Review of the physician's orders both dated for 05/03/23 for the resident revealed an order for 2000 milliliters (ml) fluid restriction for every shift with special instructions: 1200 ml-dietary, 800 ml-nursing (400 ml-for day shift and 400 ml for night shift). Review of the treatments administration record (TAR) for the months of November 2023, December 2023 and January 2024 for 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 interview, record review, policy review and Centers for Disease Control and Prevention (CDC) immunization guidance the facility failed to offer timely Covid-19 vaccine information and the option to get updated Covid-19 vaccines. This affected three (Resident #27, Resident #32, and Resident #77) of five residents reviewed for Covid-19 Vaccinations. The facility census was 84. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 03/31/23. Continued reviewed revealed the facility had not offered him information regarding Covid-19 vaccine. Review of Resident #27 immunization record revealed his last Covid vaccines were completed on 3/5/21 and 4/26/21. Interview on 02/05/24 at 3:19 P.M. the Director of Nursing (DON) revealed the facility did not offer Resident #27 the opportunity to receive information regarding the Covid-19 vaccine. 2. Review of the medical record for Resident #32 revealed an admission date for 08/24/23. Continued review revealed the facility 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 payroll based journal review, email correspondence review, and interview, the facility failed to timely submit federally required staffing information to the Centers of Medicare and Medicaid Services (CMS). This had the potential to affect all 93 residents residing in the facility. Findings include: Review of the Payroll Based Journal (PBJ) for the 2nd quarter timeframe dated 04/01/23 to 06/30/23 revealed the facility had low weekend staffing and a high number of days with no registered nurse. Review of the email correspondence with CMS dated 08/15/23 revealed Staff #17 informed CMS that due to a technical issue on their end, their hours reported by the deadline of midnight on 08/14/23 was not submitted. CMS responded that unfortunately it was not possible and providers were given 45 days from the end of the quarter to submit their data and CMS had cautioned providers that they should not be waiting until the last few days before the deadline to begin their submissions as there needs to be time allowed to deal with any issues that may occur. On 12/04/23 at 9:55 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to maintain resident dignity with use of an indwelling urinary catheter. This affected one resident (#54) of three residents reviewed for activities of daily living. The facility identified four residents with indwelling catheters. The facility census was 93. Findings include: Medical record review revealed Resident #54 was admitted on [DATE] with diagnoses including diabetes mellitus, urinary retention with bilateral hydronephrosis and cerebral infarction. Review of the Nursing Admission- Clinical admission Documentation dated 12/02/23 revealed Resident #54's primary diagnosis was urinary retention, was cognitively intact for daily-decision making and had an indwelling urinary catheter. Review of the Baseline Care Plan dated 12/02/23 revealed Resident #54 had an internal urinary catheter with goals including the resident's dignity was not to be altered related to the catheter use. Interventions included the internal urinary catheter…

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 residents had access to their call lights. This affected two residents (#23, #81) of three residents reviewed for activities of daily living. The facility census was 93. Findings include: On 12/04/23 at 7:55 A.M., 8:08 A.M., and 8:19 A.M., observations revealed Resident #23's call light was rolled up in a circle and looped on the corner of the head board. The call light was not within reach of Resident #23. On 12/04/23 at 8:19 A.M., interview with Licensed Practical Nurse (LPN) #6 verified Resident #23's call light was not in reach of the resident and LPN #6 was observed moving the head board of the bed away from the wall to unloop the call light to put it within reach of the resident. On 12/04/23 at 8:41 A.M., interview with the Director of Nursing verified resident call lights were to be within reach at all times and stated the facility did not have a policy for call lights. On 12/04/23 at 3:35 P.M., observation revealed Resident #23's call light was located on the floor under the resident's bed out of reach. 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, medical record review, policy review and interview, the facility failed to ensure resident information remained confidential. This affected one resident (#90) of 93 residents residing in the facility. Findings include: On 12/07/23 at 1:05 P.M., observation of the 300 unit revealed a medication cart was positioned across from the nursing station against the wall next to the television/lounge area. Residents were being assisted in the dining room and no nurse was observed. Further observation revealed a laptop computer was sitting on top of the cart with the screen raised. The laptop was on and the screen revealed a picture and personal information regarding Resident #90 including her date of birth , age, allergies, diagnoses and diet. There were also a picture of Resident #90 on the screen. On 12/07/23 at 1:07 P.M., interview with Registered Nurse #8 verified the above observation and confidential resident information was visible. Review of the undated policy: HIPAA (Health Insurance Portability and Accountability Act) revealed not to leave written documents…

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 provide assistance as needed with dining. This affected two residents (#68, #81) of three residents reviewed for activities of daily living (ADL). The facility census was 93. Findings include: 1. Medical record review revealed Resident #68 was admitted on [DATE] with diagnoses including but not limited to Alzheimer's disease, coronary disease and anxiety disorder. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #68 was moderately impaired for daily decision-making and required set-up and clean up assistance with eating. 2. Medical record review revealed Resident #81 was admitted on [DATE] with diagnoses including syncope and collapse, repeated falls, unspecified dementia, osteopenia (bone loss), and Parkinson's disease. Review of the discharge return-anticipated MDS assessment dated [DATE] revealed Resident #81 was moderately impaired for daily decision-making and required set-up 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 observation, medical record review, policy review, and interview, the facility failed to ensure fall interventions were in place and interventions were immediately implemented to maintain resident safety after a fall. This affected one resident (#81) of three residents reviewed for accidents/incidents. The facility census was 93. Findings include: Review of the medical record revealed Resident #81 was admitted on [DATE] with diagnoses including syncope and collapse, repeated falls, unspecified dementia, osteopenia (bone loss), and Parkinson's disease. Review of the discharge return anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #81 had one fall with a major injury since the last assessment. Review of the Physician Progress Note dated 10/10/23 revealed Resident #81 had poor insight, confusion and severe spinal deformity due to kyphoscoliosis. The physician's impression was degenerative changes and osteopenia. The Fall Assessment & Plan was to continue fall precautions,…

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, policy review and interview, the facility failed to provide adequate incontinence care to dependent residents. This affected one resident (#8) of three residents reviewed for urinary incontinence. The facility census was 93. Findings include: Medical record review revealed Resident #8 was admitted on [DATE] with diagnoses including irritable bowel syndrome, overactive bladder, heart failure, Alzheimer's disease and seizure disorder. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact for daily decision-making and was frequently incontinent of bowel and bladder. Review of the Progress Notes dated 11/03/23 revealed an urine culture was obtained via straight catheterization and the urine was cloudy yellow with a strong odor. An urine culture results were received from the laboratory on 11/06/23 indicating Escherichia coli (bacteria) greater than 100,000 CFU per milliliter. Review of the Physician Orders 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 medical record review and interview, the facility failed to ensure medical records were accurate. This affected one resident (#81) of three residents reviewed for incidents and one resident(#67) of three residents reviewed for pressure ulcers. The facility census was 93. Findings include: 1. Medical record review revealed Resident #81 was admitted on [DATE] with diagnoses including syncope and collapse, repeated falls, unspecified dementia, osteopenia (bone loss), and Parkinson's disease. Review of the Event Report dated 10/19/23 revealed Resident #81 had an incident at 12:00 P.M. resulting in redness to the right side of the forehead. A fall occurred in the resident room and Resident #81 was ambulating just prior to the fall. Review of Resident #81's undated Incident Reassessment Summary revealed there were witnesses to the above incident and immediate safety approaches included a PT (Physical Therapy) evaluation, treatment as indicated and a TLSO (a back brace used to limit motion in the thoracic,…

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, and interview, the facility failed to ensure pressure relieving devices were in place for Resident #3 and Resident #4. This affected two residents (#3 and #4) of three residents reviewed for pressure ulcers. Facility census was 96. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included but not limited to acute cholecystitis, sepsis, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and Parkinson's disease. Review of Clinical admission Documentation dated 06/02/23 at 2:40 P.M. revealed Resident #3 was at high risk for skin breakdown. Review of a progress note dated 06/03/23 at 1:31 A.M. revealed Resident #3 arrived at the facility and had a wound vac to coccyx and non-blanchable soft heels. Plan of care dated 06/05/23 revealed Resident #3 had a pressure injury to coccyx, right heel, and left heel. Interventions included an air mattress and Pro Heel X Boots to be worn in bed. Review of wound grid…

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

Based on observation and staff interview the facility failed to ensure food preparation and serving areas were clean and sanitary. This had the potential to affect 79 of 79 residents who received meal trays from the kitchen. The facility identified one resident (#10) who received nothing by mouth. The facility census was 80. Findings include: On 01/12/22 at 11:30 A.M. observation of the lunch meal tray line revealed the food items had been prepared and the tray line was set up for meal service. At the time of the observation, the metal cover on the noodles was observed to have dried bread crumbs on it. The metal cover on the roast pork was observed to have dried cheese on it. The steam table had dried food debris on it. The steamer and oven had grease encrusted dust and food debris on it. The plate warmer had a build-up of food debris on the top of it. On 01/13/22 at 4:40 P.M. during an interview with Dietary Manager (DM) #16, the DM verified the condition of the tray line service items, steamer, oven and plate warmer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure a summary of the initial (baseline) care plan was provided to each resident and/or their representative at the time of admission. This affected five residents (#10, #11, #50, #75 and #226) of 18 sampled residents reviewed for baseline care planning. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), benign neoplasm of cerebral meninges, chronic respiratory failure, dysphagia, anorexia, essential hypertension, hyperlipidemia and localized right hand edema. Resident #10 had a baseline care plan developed 09/11/2021. However, there was no evidence it was provided to Resident #10 and/or her representative. On 01/10/22 at 3:00 P.M. interview with Resident #10 revealed she was not provided an initial care plan. On 01/18/22 at 3:41 P.M. interview with Registered Nurse (RN) #300…

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 and procedure review and interview the facility failed to ensure admission/quarterly care planning conferences were held on behalf of the residents with all required disciplines in attendance. This affected four residents (#18, #64, #70 and #226) of four sampled residents reviewed for care plans conferences Findings include: 1. A review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, unsteadiness on her feet, end stage renal disease, dependence on renal dialysis, congestive heart failure, hypertension, adult onset diabetes mellitus, major depressive disorder, and anxiety disorder. The resident's emergency contact included her son, who was her resident representative. A review of Resident #18's Minimum Data Set (MDS) 3.0 assessments revealed the resident had an admission MDS 3.0 assessment completed on 10/13/21. The assessment revealed the resident did not have any communication 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 observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #15, Resident #52 and Resident #56 were provided the necessary care and services to maintain/promote optimal nutrition and the ability to eat and failed to ensure Resident #18 received the necessary care and services to maintain optimal oral hygiene. This affected four residents (#15, #18, #52 and #56) of seven residents review for activities of daily living (ADL) care. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder, anxiety, abnormal weight loss, restlessness and agitation. Review of Resident #15's plan of care, dated 04/16/18 revealed offer resident verbal cues if needed for chewing and swallowing or to finish eating. The care plan also revealed to offer assistance with feeding if needed. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0…

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

Based on observation, record review and interview the facility failed to ensure residents ordered a low concentrated sweets diet were provided the diet/dessert as ordered during the lunch meal on 01/12/22. This affected 26 residents (22, #40, #8, #400, #11, #14, #26, #38, #7, #36, #18, #228, #23, #20, #42, #9, #29, #1, #48, #41, #71, #229, #53, #47, #25, and #376) of 26 residents who had an order for a low concentrated sweets diet. The facility census was 80. Findings include: On 01/12/22 at 11:30 A.M. observation of lunch meal tray line revealed all residents who had orders for a low concentrated sweets diet received apple cobbler. Review of the menu for the lunch meal on 01/12/22 revealed the low concentrated sweets diet included fruit for the dessert on this date. On 01/13/22 at 4:04 P.M. interview with Dietary Manager (DM) #16 confirmed the residents ordered a low concentrated sweets diet were not provided the proper dessert during the lunch meal on 01/12/22. DM #16 confirmed the residents should have been provided fruit and not apple cobbler. The facility identified 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.

3. On 01/11/22 at 9:00 A.M. STNA #47 was observed in Resident #64's room. Resident #64 was in contact/ droplet isolation precautions as evidenced by signs on the resident's door indicating such and a personal protective equipment (PPE) cart outside of his room. STNA #47 was observed to be standing next to the bed where Resident #64 was lying in. STNA #47 was within a few feet of the resident and was observed to be taking the resident's meal order. STNA #47 placed the select menu on the resident's bedside table as he recorded the resident's responses for what he wanted to eat for an upcoming meal. STNA #47 was not noted to be wearing a gown or gloves when in the resident's room. The STNA was observed wearing goggles and an N95 mask as the facility staff were wearing throughout the building as they had a Covid-19 outbreak occurring. STNA #47 was observed to go to the bathroom to wash his hands before leaving the resident's room. He was stopped several feet down the hall as he left the resident's room and was heading in the direction of the nurses' station. On 01/11/22 at 9:07 A.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #45's urinary catheter drainage bag was covered to promote the resident's dignity. This affected one resident (#45) of five residents identified to have indwelling urinary (Foley) catheters. Findings include: Review of Resident #45's medical record revealed an original admission date of 08/15/21, with a re-admission from the hospital on [DATE]. Resident #45 had diagnoses including metabolic encephalopathy, pressure ulcer of sacral region, cerebral infarction with left sided hemiplegia, chronic kidney disease and urinary retention. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22 revealed the resident was moderately cognitively impaired, required staff assistance to complete activities of daily living, had a Foley catheter for urinary drainage and an ostomy for bowel movement. Review of the physician's orders for January 2022 revealed an order for 16 French…

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, facility policy and procedure review and interview the facility failed to ensure Resident #55, who was receiving anticoagulant medication was monitored for bruising and also failed to monitor/ record Resident #70's gastric residual amounts emptied from a gastrostomy tube as ordered by the physician. This affected one resident (#55) of one resident reviewed for anticoagulant medication side effects and one resident (#70) of one resident reviewed for tube feedings. Findings include: 1. A review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] following a hospitalization for a dislodgement of her gastrostomy tube (feeding tube). Resident #70 had diagnoses including a neoplasm of the trachea/ bronchus and the upper lobe of the right lung and dysphagia. A review of Resident #70's hospital records for her stay between 11/27/21 and 12/06/21 revealed the resident was suspected as having aspiration…

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, facility policy and procedure review, review of a Nursing Assistant Candidate handbook and interview the facility failed to provide adequate and complete perineal care for Resident #67 to prevent the risk of infection. The facility also failed to ensure Resident #52 was assessed timely for the removal of an indwelling urinary catheter and failed to ensure proper placement of the resident's catheter to prevent contamination/infection. This affected one resident (#67) of one resident observed for perineal care and one resident (#52) of one resident reviewed for indwelling urinary catheter use. Findings include: 1. Review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including overactive bladder, hemiplegia, cerebral infarction and dermatitis. Review of Resident #67's quarterly Minimum Date Set (MDS) 3.0 assessment, dated 12/12/21 revealed the resident was always incontinent of bowel and bladder and was not on 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 observation, record review and interview the facility failed to ensure Resident #56, who had a history of weight loss received the appropriate diet as ordered and assistance with meals to meet her nutritional needs and failed to ensure dietary recommendations to address Resident #45's significant weight loss were followed up timely. This affected two residents (#45 and #56) of six residents reviewed for nutrition. Findings include: 1. Review of Resident #56's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia, osteoarthritis, needs assistance with personal care, type two diabetes, and age-related physical debility. Review of Resident #56's current plan of care revealed to offer and/or provide food substitute of equal nutritive value if intake was less than 50% at meals and to honor food preferences as available and reasonable. Further review of the nutritional plan of care revealed the resident was noted to have significant weight loss from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #18's oxygen tubing was changed weekly as per facility policy. This affected one resident (#18) of two residents reviewed for respiratory care. Findings include: A review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure and obstructive sleep apnea. A review of Resident #18's physician's orders revealed the resident had an order to receive continuous oxygen at two liters per minute (LPM) per nasal cannula. The orders did not provide any instruction on how often the oxygen tubing was to be changed. A review of Resident #18's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/13/21 revealed the resident did not have any communication issues and was cognitively intact. She was not noted to display any behaviors nor was she known to reject care. Oxygen therapy was coded on the MDS as having…

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 an accurate diagnosis and monitoring of a psychoactive (benzodiazepine) medication for Resident #73. This affected one resident (#73) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including left shoulder pain, Parkinson's disease, fibromyalgia, neuropathy, chronic pain, migraines, dementia, anxiety and major depression. Review of Resident #73's physician's orders and medication administration records (MAR) dated 12/13/21 to 01/11/22 revealed the resident was ordered the benzodiazepine, Diazepam two milligrams (mg) in the morning and four mg in the evening for restlessness on 12/14/21. The resident's pain was monitored each shift and with no pain noted except for on four occasions during the time period when the pain ranged from a two to five on a scale of one to ten with ten being the most severe pain. Further 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.