Continuing Healthcare At Willow Haven

Based on record review, interview and review of facility's medication administration policy, the facility failed to ensure medical records were accurate and complete regarding the administration of controlled substances. This affected two (Resident #55 and #56) of 25 residents reviewed for medication administration. The facility census was 74. Findings include:1. Review of the medical record for Resident #56 revealed an admission date of 04/08/25 with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, weakness, acquired absence of left leg above knee, muscle weakness, depression, and chronic kidney disease.Review of the care plan dated 09/09/25 revealed the intervention to give analgesics as ordered by the physician and to monitor/document for side effects.Review of a physician order dated 10/31/25 revealed the order for Hydrocodone-Acetaminophen 5-325 milligrams (mg) (opioid pain medication) one tablet by mouth every eight hours as needed for moderate to severe pain.Review of Resident #56's Individual Patient Controlled Substance Administration Record…

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 staff schedule review, payroll-based journal review, facility assessment review, policy review and interview, the facility failed to ensure adequate staffing to meet the needs and staffing as identified in the facility assessment. This had the potential to affect all residents residing within the facility. The census was 68. Findings Include: Review of the Facility Assessment Tool revised 03/24/25 revealed the facility average daily census was 69 to 78 residents. The facility staffing plan was based on the resident population and their varying needs for care and services, the general approach to help the facility gauge sufficient staff to assist in meeting the needs of the residents at any given time involves various factors including: The range of facility staff that may be needed to gauge sufficient qualified staff available to meet each resident's needs may be based on resident AOL acuity, medical complexities, behavioral/psychosocial needs of the residents, and the ebb and flow of day/night routine needs to name a few. This data can be obtained from sources such as the…

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

Based on payroll-based journal review, staffing schedule review, policy review and interview, the facility failed to provide eight hours of consecutive registered nurse (RN) hours per day. This had the potential to affect all 68 residents residing within the facility. Findings include: Review of the Payroll-Based Journal second quarter 2025 revealed the facility did not meet the requirement of having a RN for eight consecutive hours daily. Review of the Facility Assessment Tool revised 03/24/25 revealed the facility average daily census was 69 to 78 residents. The facility staffing plan was based on the resident population and their varying needs for care and services, the general approach to help the facility gauge sufficient staff to assist in meeting the needs of the residents at any given time involves various factors. Review of the Staffing Schedules dated January 2025 through July 2025 revealed there was no consecutive eight hour RN coverage on the following dates: 01/18/25, 01/19/25, 02/01/25, 02/02/25, 03/16/25, 04/12/25, 04/13/25, 04/19/25, 04/20/25, 04/26/25, 05/04/25,…

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

Based on observation, manufacturer review, policy review and interview, the facility failed to maintain a safe and sanitary kitchen. This had the potential to affect all 68 residents that received food from the kitchen. Findings include: 1.On 08/11/25 between 8:20 A.M. and 8:45 A.M., initial observation of the kitchen revealed Dietary Aide #111 and Dietary [NAME] #128 were preparing and serving breakfast meals. Dietary [NAME] #128 was observed serving an omelet that was dark brown and overcooked. Dietary [NAME] #128's hairnet did not encase all of her hair in the front and both sides. Dietary [NAME] #128 verified the above and she stated she was new to the position. Observation of the reach-in refrigerator revealed no temperature was displayed on the thermometer. Water was observed leaking in the same reach-in refrigerator. The reach-in refrigerator contained a gallon of whole milk, 13 glasses of chocolate milk and three additional cafeteria-style trays each containing glasses of apple juice, cranberry juice and fruit punch. The chocolate milk and juice glasses were covered with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility surety bond, review of fund balance form, and interview the facility failed to ensure the surety bond had not lapsed. This affected 42 residents (Resident #11, #12, #13, #15, #16, #17, #19, #22, #23, #26, #27 (two accounts), #2 (two accounts), #28, #29, #31, #33, #34, #3, #39, #40, #5, #42, #43, #45, #47, #48, #49, #51, #52, #54, #8, #55, #10, #58, #59, #60, #61, #62, #65, #64, #9 (two accounts), and #67 out of 68 residents identified as having a resident funds account. Findings Include:Review of resident funds balance form dated [DATE] revealed there was 45 accounts for 42 residents (Resident #11, #12, #13, #15, #16, #17, #19, #22, #23, #26, #27, (two accounts), #2 (two accounts), #28, #29, #31, #33, #34, #3, #39, #40, #5, #42, #43, #45, #47, #48, #49, #51, #52, #54, #8, #55, #10, #58, #59, #60, #61, #62, #65, #64, #9 (two accounts), and #67 totaling $28,884.44. Review of the surety bond dated [DATE] revealed the surety bond was effective from [DATE] and expired on [DATE]. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and interview, the facility failed to maintain a clean and sanitary physical environment, failed to ensure a homelike dining experience and failed to ensure adequate supplies/linens were available for resident use. This affected 16 residents observed eating in the main dining room (Resident #2, #3, #6, #8, #15, #18, #19, #20, #25, #28, #29, #31, #44, #45, #47, and #52), three resident's (#9, #69 and #80) air conditioner unit, nine resident rooms (Resident's #2, #6, #8, #18, #19, #45, #47, #65 and #80) and had the potential to affect all 68 residents residing within the facility. 1.On 08/11/25 between 11:28 A.M. and 11:35 A.M., observation and interview with Resident #59 revealed upon entering the room the floor was sticky causing your shoes to make a snapping noise as you walked across the floor. Interview with Resident #59 at the time of the observation revealed she was unaware what was on the floor that made the entire floor sticky and she said it had been that way for a day…

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

Based on medical record review, observation, interview, and policy review, the facility failed to ensure dependent residents were assisted with nailcare and shaving. This affected four residents (#2, #5, #10 and #19) of seven residents reviewed for activities of daily living. The census was 68. Findings Include:1. Review of Resident #2's medical record revealed a 07/12/25 admission with diagnoses including fracture of left femur, vascular dementia, hypertensive heart disease, congested heart failure, depression, muscle wasting and atrophy, abnormalities of gait and mobility, weakness, history of falling, anxiety disorder, Vitamin B deficiency, chronic stage III kidney disease, gastroesophageal reflux disease, disorientation, hypertension, spondylolisthesis lumbar region, and cardiac murmur.Review of a 07/19/25 Quarterly Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making and needed substantial/maximum assist for personal hygiene.Review of the resident record included a plan of care dated 08/05/25 activity of daily living self-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 ensure medical records were complete and accurate. This affected four residents (#48, #72, #77, and #80) of 27 resident records reviewed.Findings Include: 1.Closed record review revealed Resident #72 was admitted to the facility on [DATE] from another long-term facility. The resident admission diagnoses included malignant neoplasm of right and left female breast, atrial fibrillation, anemia, hyperlipidemia, hypocalcemia, anxiety, insomnia, essential hypertension, constipation, psoriasis, osteoporosis, chronic kidney disease, pain, use of anticoagulants, and difficulty walking. The resident expired in the facility on [DATE]. Review of Resident #72's altered cardiovascular status/related to hypertension, atrial fibrillation initiated [DATE] and revised [DATE] to monitor/documented/report to physician as need any signs and symptoms of coronary artery disease: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness…

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, interviews, and policy reviews the facility failed to ensure enhanced barrier precaution (EBP) were implemented/maintained and infection control practices were maintained during incontinence care. This affected three residents (#1, #32, and #42) of four residents observed on 100-unit for EBP and two residents (#20 and #77) of two residents observed for incontinence care. Findings Include: 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube. Review of Resident #32' EBP plan of care dated 07/23/25 revealed to use appropriate EPB when performing the following care: dressing, bathing, showering, transferring, hygiene care, changing linen, toileting, and peri care. Dispose of EBP in the appropriate containers. Review of Resident #32 current orders revealed no evidence of orders for EBP. Interview and observation on 08/11/25 at 10:32 A.M., of Resident #32 revealed the resident had a gastrostomy…

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, review of manufacturer guidelines and interview, the facility failed to ensure an exit door, clothes dryer, air conditioner and refrigerator were maintained. This had the potential to affect all 68 residents in the facility. The census was 68.Findings Include:1.Review of an elopement investigation dated 05/19/25 revealed the facility determined the 100 hall door was not locked as the key panel indicated.Interview on 08/21/25 at 8:51 A.M. with Maintenance Staff #173 revealed the 100 hall exit door is an Advantage 500 DE System. It was not connected to a Wanderguard system. The door at the end of the 100 hall had a key pad. The door was hardwired with a battery back up. The doors had a red and green light on the keypad. Red means locked and green open. The door was pushed to see if it opened during weekly door checks. Prior to the elopement the door was last checked on 05/15/25. Maintenance Staff #173 said the day of the elopement the door keypad was showing red. However, when the door was pushed, it opened. He said they looked and the back up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, it was determined the facility failed to ensure residents' code status' were accurate. This affected two residents (#2, #72) of 28 residents reviewed for accurate code status.Findings Include: 1. Closed record review revealed Resident #72 was admitted to the facility on [DATE] from another long-term care facility. The resident admission diagnoses included malignant neoplasm of right and left female breast, atrial fibrillation, anemia, hyperlipidemia, hypocalcemia, anxiety, insomnia, essential hypertension, constipation, psoriasis, osteoporosis, chronic kidney disease, pain, use of anticoagulants, and difficulty walking. The resident expired in the facility on [DATE]. Review of Resident #72's transfer records from the other long-term facility dated [DATE] revealed the resident was admitted to the facility on [DATE] from the hospital after sustaining a fall with a fracture. Further review of the resident face sheet revealed there were no advanced directives…

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, policy review and interview, the facility failed to ensure pharmacy recommendations were addressed including a rationale for declining gradual dose reductions. This affected one resident (#67) of five residents reviewed for unnecessary medications. The census was 68.Findings Include:Medical record review revealed Resident #67 was admitted on [DATE] and readmitted on [DATE] with diagnoses including depression, anxiety disorder and traumatic subdural hemorrhage. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact for daily decision-making and had an anxiety disorder. Review of the Pharmacist's Recommendation to Prescriber dated 12/09/24 revealed Resident #67 had a PRN (as needed) order for the psychotropic medication, Lorazepam (anxiolytic) 0.5 milligrams. The pharmacist stated per CMS, PRN psychotropic medications are limited to 14 days. If use is beyond 14 days, the rationale and estimated duration of use must 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 medical record review and interview, the facility failed to complete an admission comprehensive assessment timely as required. This affected one resident (#80) of 24 residents sampled. The census was 68. Findings Include: Medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including fractured vertebrae, end stage renal disease, dependence on renal dialysis and dysphagia. The resident was discharged from the facility on 08/18/25.Review of Resident #80's Minimum Data Set 3.0 (MDS) assessments in the electronic medical record revealed no completed MDS assessments were available for review. Both the admission MDS assessment dated [DATE] and a 5-day MDS assessment dated [DATE] were not completed or submitted as required within 14 days of admission. On 08/19/25 at 3:20 P.M., interview with Registered Nurse (RN) #123 verified Resident #80 did not have a MDS assessment for review due to the assessments had not been finished or submitted to CMS to date. RN #123 stated she has been…

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 a significant change of condition Minimum Data Set (MDS) was completed timely. This affected one resident (#3) of one record reviewed for hospice. Findings Include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, peripheral vascular disease, heart failure, urinary retention, depression, and was admitted to hospice on 07/07/25. Review of Resident #3's orders dated 07/07/25 revealed the resident was admitted to hospice. Review of Resident #3's hospice plan of care dated 07/10/25 revealed the resident/responsible party had elected to utilize hospice/end-of-life care services. Review of Resident #3's MDS revealed no evidence of significant change of condition MDS was completed. Interview on 08/19/25 at 3:22 P.M., with Registered Nurse/MDS Nurse #123 confirmed Resident #3 should have had a significant change of MDS completed on 07/07/25 when 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 and interview, the facility failed to ensure comprehensive assessments were accurate. This affected one resident (#54) of 24 residents reviewed for comprehensive assessments. The census was 68.Findings include:Medical record review revealed Resident #54 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #54 received one dose of insulin. Review of the electronic Physician Orders dated May 2025 revealed Resident #54 did not have an order for insulin. Review of the electronic Medication Administration Record dated May 2025 revealed Resident #54 did not receive insulin during the quarterly MDS assessment reference dates. On 08/18/25 at 12:28 P.M. interview with Registered Nurse #123 verified Resident #54 did not receive insulin and the MDS assessment was not accurate.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure residents maintained activities of daily living including range of motion and ambulation. This affected one resident (#59) of six residents reviewed for activities of daily living (ADL). The census was 68.Findings include: Medical record review revealed Resident #59 was admitted on [DATE] with diagnoses including heart failure, unspecified dementia, muscle weakness and cognitive communication deficit. The resident had been receiving hospice services in 2024; however, Resident #59 was discharged from hospice on 01/01/25. Review of the OT (occupational therapy) Discharge summary dated [DATE] revealed therapy recommended ADL assist as needed with no restorative or functional program indicated at that time. Review of the BCRS Scoring Worksheet dated 06/23/23 through 08/15/24 revealed Resident #59 required no assistance with ambulation. There was no therapy screens completed in 2024; however, a therapy screen was completed after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to obtain treatment orders and comprehensively assess skin alterations. This affected two residents (#19, #77) of three residents reviewed for care and treatment.Findings Include: 1.Review of Resident #19's medical record revealed a 07/17/24 readmission with diagnoses including lymphedema, dysphasia, anemia, proximal atrial fibrillation, acquired absence of left toes, chronic kidney disease stage three, venous insufficiency, chronic diastolic congestive heart failure, hyponatremia, hyperlipidemia, benign prostate hyperplasia, bladder neck obstruction, type two diabetes, severe protein calorie malnutrition, vitamin D deficiency, chronic respiratory failure, chronic kidney disease and disorder, Parkinson's disease, major depressive disorder and pyoderma gangrenosum, a rare inflammatory skin disease where painful pustules or nodules become ulcers that progressively grow. The resident had a plan of care dated 03/25/24 Activity of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, policy review, and interview the facility failed to complete comprehensive assessment of pressure ulcer skin impairments, failed to provide pressure prevention interventions, and failed to follow infection control practices during the changing of a pressure ulcer dressing. This affected one resident (#77) of three residents reviewed for pressure ulcers. The facility census was 68. Findings Include:Medical record review revealed Resident #77 had multiple admissions to the facility and was most recently admitted on [DATE] with diagnoses including peripheral arterial disease, diabetes mellitus, bilateral below the knee amputations (BKA) and multiple wounds. Review of the census revealed the resident was discharged to the hospital on [DATE] with a diagnosis of encephalopathy and returned to the facility on [DATE]. Review of the Illustration of Documentation and Measurements of Skin Areas dated 08/08/25 revealed an open area measuring 0.5 centimeters (cm) in length (l) by…

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 hospital records, and interview the facility failed to ensure a resident gastrostomy tube was properly managed. This affected one resident (#32) of one resident reviewed for gastrostomy tube. The facility census was 68.Findings Include: Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including unspecified protein-calorie deficit, gastrostomy, gastro-esophageal reflux disease, bariatric surgery status, peritoneal abscess, pain, vitamin deficiency, nausea with vomiting, hypokalemia, insomnia, muscle spasms, vitamin D deficiency, sepsis, chronic obstructive pulmonary disease, drug induced subacute dyskinesia, type diabetes, muscle wasting, muscle weakness, depression, attention-deficit hyperactivity, venous insufficiency, and atherosclerotic heart disease. Review of Resident #32's hospital discharge orders dated 07/23/25 revealed to repeat the computed tomography (CT) scan next week. The office will call with appointment.…

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 respiratory equipment was maintained in a sanitary manner and failed to assist with the application of a respiratory device. This affected three residents (#5, #45 and #48) of three residents reviewed for respiratory care. The census was 68.Findings Include:1.Review of Resident #48 revealed a 05/18/22 admission with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, Obstructive sleep apnea (OSA), diabetes, asthma, hemiplegia, and anxiety disorder. Review of the 06/30/25 Quarterly Minimum Data Set Assessment included the resident was moderately impaired for daily decision, on oxygen and a non invasive mechanical ventilator. Physician orders included an order dated 03/25/22 for non-invasive home ventilator (Trilogy machine) Settings: AVAPS-AE Breath Rate: Auto Inspiratory time: N/A Sigh: off mouthpiece ventilation: NO PS min-5 comment-20 PS max-20 comment-25 EPAP min-5 EPAP max:15 AVAPS…

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, dialysis contract review, policy review and interview, the facility failed to ensure ongoing communication with the dialysis center, failed to fulfill the dialysis center contract as agreed upon and failed to ensure dialysis orders were acted upon timely and administered. This affected one resident (#80) of one resident reviewed for dialysis. The census was 68. Findings include: Medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including vertebrae fractures, end stage renal disease, dependence on renal dialysis (hemodialysis), diabetes mellitus, hypocalcemia and depression. Resident #80 was discharged back to the community on 08/18/25. Review of the electronic Physician Orders dated August 2025 revealed Resident #80 was scheduled to have dialysis every Monday, Wednesday and Friday from 6:00 A.M. to 10:00 A.M. Review of the care plan dated 08/07/25 revealed Resident #80 needed hemodialysis related to end stage renal disease. On 08/13/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, job description review and interview, the facility failed to timely provide psychiatric services as indicated by mood symptoms. This affected one resident (#46) of five residents reviewed for unnecessary medications. The census was 68. Findings include:Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including cerebral infarction, intracerebral hemorrhage, bipolar disorder, depressed mild or moderate severity and anxiety disorder.Review of the electronic Physician Orders dated August 2025 revealed Resident #46 was receiving Abilify (antipsychotic) 5 milligrams (mg) at bedtime, prozac (antidepressant) 30 (mg) in the morning, trazodone (antidepressant) 150 (mg) at bedtime, lamictal 100 (mg) for mood stabilization and buspirone (anxiolytic) 15 (mg) three times a day for anxiety. Review of the care plan: Potential to have Mood Problem related to chronic obstructive pulmonary disease, cognitive communication deficit, depression, bipolar 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, observation, interview, and policy review the facility failed to ensure expired insulin was discarded. This affected one resident (#77) of three residents with insulin pens observed in the 200-medication cart. The facility census was 68. Findings Include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] from a sister facility with diagnoses including diabetes, heart disease, and chronic kidney disease. Review of Resident #77 orders dated 08/2025 revealed Humalog Kwikpen subcutaneous pen injector inject per sliding scale before meals. There was no evidence the resident was ordered Novolog. Review of Resident #77 Medication Administration Records (MAR) revealed Resident #77 received Humalog per sliding scale 11 times from [DATE] to [DATE]. Observation on [DATE] at 8:32 A.M., of the 200-medication cart with Licensed Practical Nurse (LPN) #149 revealed Resident #77 had three Humalog pens. One Humalog pen was not opened and two were opened and 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, policy review and interview, the facility failed to adequately monitor for appropriate use of opioids. This affected one resident (#67) of five residents reviewed for unnecessary medications. The census was 68. Findings include: Medical record review revealed Resident #67 was admitted on [DATE] with diagnoses including osteoarthritis, spinal stenosis cervical region, arthrodesis status, traumatic subdural hemorrhage without loss of consciousness and muscle wasting. Review of Resident #67's care plan: Risk for Pain related to osteoarthritis, diabetes mellitus, GERD, chronic kidney disease, spinal stenosis, diverticulosis, previous subdural hemorrhage and atherosclerosis of aorta revised 04/11/25 revealed to administer analgesia per orders, anticipate the resident's need for pain relief and respond immediately for complaints of pain. Review of the care plan did not include any individualized non-pharmacological interventions for pain management. Review of the quarterly Minimum Data…

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 hospital discharge orders, and interview the facility failed to ensure laboratory testing was performed per orders. This affected one resident (#82) of six residents reviewed for medication review. Findings Include:Closed medical record review revealed Resident #82 was admitted to the facility on [DATE] and discharged on 06/30/25 with diagnoses including osteomyelitis, diabetes, methicillin susceptible staphylococcus aureus, and absence of left foot. Review of Resident #82's discharge hospital notes dated 06/16/25 revealed orders for the following laboratory work: weekly complete blood count (CBC), basic metabolic profile (BMP), and creatine Kinase (CK) weekly until 07/16/25. Review of Resident #82's medical record revealed no evidence a CBC, BMP, or CK was performed. Interview via email on 08/19/25 at 8:46 P.M., with Corporate Regional Nurse (CRN) #193 confirmed the resident did not have weekly labs per discharge orders. Interview on 08/20/25 at 9:00 AM with Licensed…

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 infection control log, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected two residents (#1 and #83) of four residents reviewed for antibiotic stewardship. Findings Include: 1. Closed medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including sepsis of unspecific organism, metabolic encephalopathy, diabetes, respiratory failure, heart disease, and pressure ulcer. Review of Resident #83's orders revealed on 06/01/25 the resident was ordered Cefdinir 300 milligrams (mg) by mouth twice daily for wound infection. On 06/03/25 the order was changed to Cefdinir 300mg by mouth twice daily for sepsis, likely respiratory until 06/05/25. Review of Resident #83's Medication Administration Record (MAR) dated 06/20/25 revealed Resident #82 received Cefdinir 300 mg from 06/01/25 to 06/03/25 for wound infection and from 06/03/25 to 06/05/25 for sepsis, likely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's Resident Welcome Packet, resident interview, and staff interview, the facility failed to ensure residents were afforded the right to have their mail delivered to them unopened. This affected two residents (#19 and #69) of three residents reviewed. Findings include: 1. Review of Resident #19's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting his left, non-dominant side and cognitive communication deficit. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. On 03/14/25 at 10:12 A.M., an interview with Resident #19 revealed he had concerns with his mail being delivered to him already opened by the facility staff. He reported the incident occurred about two to three weeks ago and he denied that he had given the facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure timely resolution of a concern regarding missing resident property. This affected one (Resident #10) of three residents reviewed for misappropriation. The facility census was 74. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, anxiety disorder, depression, and personal history of malignant neoplasm of the lip, oral cavity, and pharynx. The resident expired and was discharged on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderately impaired cognition. Review of a Concern Report, dated [DATE], revealed Resident #10's power-of-attorney (POA) filed a concern regarding Resident #10's missing rollator walker, dentures, and glasses following a hospitalization on [DATE]. The Concern Report revealed the Administrator called the inpatient psychiatric…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review and interview, the facility failed to ensure comprehensive resident information was provided to the receiving facility regarding a transfer. This affected one (Resident #10) of three residents reviewed for death. The facility census was 74. Findings include: Review of the closed medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, anxiety disorder, depression, and personal history of malignant neoplasm of the lip, oral cavity, and pharynx. The resident expired in the facility and was discharged on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderately impaired cognition. The resident required supervision or touching assistance with ambulation, showering, and personal hygiene. Review of Resident #10's Transfer Form, dated [DATE], revealed under Section E: the facility failed to include accurate resident representative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of a facility investigation and follow up, and staff interview the facility failed to ensure coordination of care for Resident #79 related to a gynecology appointment to timely address medical symptoms. This affected one resident (#79) of three residents reviewed for appointments. The facility census was 76. Findings include: Review of Resident #79's closed medical record revealed an admission date of 04/30/24 and a discharge date of 11/11/24. Resident #79 had diagnoses including multiple sclerosis, anxiety disorder, chronic kidney disease stage four, chronic diastolic heart failure, and anxiety. Review of Resident #79's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #79's progress note dated 10/23/24 revealed there was a new order for a referral to gynecology 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, review of concern reports, review of dental treatment plan quotes, email correspondence between facility staff and the corporate office, resident interview, family interview, staff interview, and policy review, the facility failed to ensure a resident's concern pertaining to missing upper dentures were addressed timely for a resolution. This affected one (Resident #17) of three residents reviewed for missing property. Findings include: Review of Resident #17's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis affecting his left non-dominant side, bipolar disorder, major depressive disorder, abnormalities of gait and mobility, and bilateral hearing loss. Review of Resident #17's profile revealed his payer status was Ohio Medicaid (MCD). The census tab in the electronic medical record revealed the resident resided on the 400 hall when he was first admitted and was moved to the 100 hall on 08/09/24. Review of Resident #17's…

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

Based on observation, maintenance log review, weather history review, policy review and interview, the facility failed to maintain a comfortable and safe living environment. This affected five residents (#105, #108, #110, #111, and #114) in the facility. The census was 71. Findings include: 1. Review of the electronic 2024 AccuWeather History for June 2024 revealed the following air temperatures for Zanesville, Ohio between 06/17/24 and 06/22/24 during the excessive heat advisory that was issued. The below temperatures did not include humidity which had effects on the real feel temperature: On 06/17/24, 95 degrees (F). On 06/18/24, 93 degrees (F). On 06/19/24, 87 degrees (F). On 06/20/24, 92 degrees (F). On 06/21/24, 94 degrees (F). On 06/22/24, 94 degrees (F). Review of the facility Air Temperature Logbook Documentation dated 06/20/24 revealed the following temperatures: Hall 100, 74 degrees (F) Hall 200, 75 degrees (F) Hall 300, 72 degrees (F) Hall 400, 72 degrees (F) Hall 500, 75 degrees (F). The resident rooms all had individual AC units that were functioning. On 06/24/24 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.

Based on observation, policy review and interview, the facility failed to maintain a safe and hazard free environment. This had affected 14 residents (#101, #109, #114, #115, #117, #119, #125, #130, #138, #140, #156, #164, #166 and #171) identified by the facility as cognitively impaired and independent with mobility. The census was 71. Findings include: On 06/24/24 from 8:06 A.M. to 8:20 A.M., observation revealed large portable air conditioning units were being utilized on each hallway with dual vent coils extending up to the ceiling. Fans were observed sitting on the floor in the hallways including three freestanding 22 inch metal fans, one 25 inch high velocity fan, one box fan and two standup cylinder fans. Interview with Environmental Services Director (ESD) #5 at the time of the observation revealed the facility's main air conditioning (AC) units were not working, the fans in the hallways were to keep the air circulating and residents had unrestricted access to the fan blades through the slats on the fan cover. Interview on 06/24/24 at 8:55 A.M., with Maintenance Supervisor…

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 interview, the facility failed to ensure residents had a homelike environment. This affected two (Residents #3 and #38) of five residents reviewed for physical environment. The facility census was 78. Findings included: 1. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, heart failure, and hypertension. Review of a quarterly minimum data set (MDS) completed on 03/11/24 revealed Resident #3 maintained cognitive function. Interview on 03/25/24 at 3:20 P.M. with Resident #3 revealed her room is not cleaned regularly, the carpet is stained and dirty, and the bucket of the bedside commode was broken and would fall out when she stood up from it. Observation on 03/25/24 at 3:32 P.M. revealed the carpet in Resident #3's room was stained heavily and was scattered with debris and a large amount of clutter in the room from clothes not being hung up or placed in drawers. 2. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's resident concern log and related reports, resident interview, staff interview, and policy review, the facility failed to ensure resident grievances/ concerns were responded to timely. This affected two (Resident #10 and #38) of two residents reviewed for personal property. Findings include: 1. A review of Resident #10's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included macular degeneration, encephalopathy, and alcohol dependence. A review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors and was not known to reject care during the seven days of the assessment period. On 03/25/24 at 10:47 A.M., an interview with Resident #10 revealed she has had some missing clothing in the recent past. She was not able to specify exactly what clothing items were missing. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to implement a care plan related to refusal of pressure ulcer interventions. This affected one (Resident #15) of four residents reviewed for pressure ulcers. The census was 78. Findings Include: Record review revealed Resident #15 was admitted to the facility on [DATE]. Her diagnoses were encounter for other orthopedic aftercare, presence of right artificial hip joint, displaced fracture of posterior wall of right acetabulum, atrial fibrillation, hypo-osmolality and hyponatremia, post traumatic stress disorder, vitamin D deficiency, morbid obesity, insomnia, hypertension, bipolar disorder, hyperkalemia, major depressive disorder, acute kidney failure, hyperlipidemia, osteoporosis, anxiety disorder, dorsalgia, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 02/02/24, revealed she was cognitively intact. Review of Resident #15's physician orders found that she had a suspected deep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to provide oral care to a resident dependent on staff for care. This affected one (Resident #43) out of four reviewed for activities of daily living. The facility census was 78. Findings Include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dysphasia, cognitive communication deficit, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely cognitively impaired and required staff assistance with oral care. Review of functional abilities and goals assessment dated [DATE] revealed Resident #43 required supervision or touch assistance with oral hygiene. Review of the self-care task, question #2 between 03/25/24 and 03/27/24 for Resident #43 revealed oral care was provided on: - 03/25/24 at 6:59 P.M. - 03/26/24 at 3:12 A.M. and 10:17 A.M. - 03/27/24 at 1:35 A.M., 3:24 P.M. and 9:52 P.M. Observations 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure a resident's bruise was timely identified and monitored as per his plan of care. This affected one (Resident #60) of two residents reviewed for non-pressure skin conditions. Findings include: A review of Resident #60's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation, anemia, vascular dementia, muscle wasting and atrophy, and abnormalities of his gait and mobility. A review of Resident #60's physician's orders revealed he was on Aspirin 81 milligrams (mg) by mouth (po) every day and Apixaban (an anticoagulant) 5 mg po twice a day. A review of Resident #60's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues, but his cognition was severely impaired. He was not known to have displayed any behaviors or was known to reject care during the seven days of the assessment period. He had a functional limitation in…

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, resident interview, staff interview, and facility policy review, the facility failed to provide options for vision and hearing services to all residents, and failed to timely schedule all vision/hearing appointments as desired by the residents. This affected three (Residents #49, #35, and #66) of three residents reviewed for ancillary services. The census was 78. Findings Include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses were sepsis, cutaneous abscess of abdominal wall, necrotizing fasciitis, infection due to other bariatric procedure, type II diabetes, morbid obesity, dysphagia, anxiety disorder, Parkinson's disease, anemia, atrial fibrillation, chronic kidney disease (stage III), peripheral vascular disease, hypertensive heart and chronic kidney disease, congestive heart failure, hyperlipidemia, hypo-osmolality and hyponatremia, lymphedema, major depressive disorder, and hypertension. Review of his minimum data set (MDS)…

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 observation the facility failed to monitor and provide appropriate incontinence care for Resident #8's urostomy. This affected one resident (Resident #48) out of one reviewed for bowel and bladder. The facility census was 78. Findings Include: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] due to Alzheimer's, chronic kidney disease, major depressive disorder, and cancer of the urinary tract system. The resident had an urostomy. Review of the Minimum Data Set (MDS) 3.0 completed on 03/12/24 revealed Resident #48 was severely cognitively impaired and required set up assistance for ADL's. Review of the Care Plan completed on 03/26/24 for Resident #48 revealed she was at risk for impaired skin integrity related to fragile skin and the ostomy or wound nurse were consulted for wound care. Resident #48 was at risk for UTI's and required staff assist with urostomy needs. Review of the care plan revealed staff are required to educate…

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 effectively communicate with a dialysis provider for Resident #66. This affected one of one resident reviewed for dialysis (#66). The facility census was 78. Findings included: Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, end stage renal disease, and heart failure. Review of orders revealed Resident #66 attends dialysis on Monday, Wednesday, and Friday. Review of a quarterly minimum data set completed on 12/22/23 revealed Resident #66's cognition remains intact. Review of Resident #66's medical record revealed there were no communications sheets from the dialysis provider from June 2023 through December 2023. There was no evidence of additional communication with the dialysis provider during this time frame. Interview on 03/27/24 at 10:26 A.M. with Licensed Practical Nurse (LPN) #158 verified no evidence of communication from dialysis from June…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to provide pain parameters for as needed pain medications, and administered as needed pain medications without pain parameters. This affected two (Residents #22 and #49) of five residents reviewed for unnecessary medications. The census was 78. Findings Include: 1. Record review revealed Resident #22 was admitted to the facility on [DATE]. Her diagnoses were unspecified fracture of shaft of left tibia and left fibula, cellulitis of right lower limb, chronic obstructive pulmonary disease (COPD), panlobular emphysema, type II diabetes, anxiety disorder, bipolar disorder, chronic kidney disease, atherosclerotic heart disease, post traumatic stress disorder (PTSD), celiac disease, fibromyalgia, schizoaffective disorder, polyosteoarthritis, congestive heart failure, hyperlipidemia, and hyperparathyroidism. Review of her minimum data set (MDS) assessment, dated 02/07/24, revealed she was cognitively 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review the facility failed to complete dental consents and/or timely schedule dental appointments for a resident. This affected one resident (Resident #35.) The census was 78. Findings include: A review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included muscle wasting and atrophy, cirrhosis of the liver, anemia, type 2 diabetes mellitus, morbid obesity, COPD, chronic kidney disease, GERD, vitamin d deficiency, anxiety disorder, and major depressive disorder. A review of Resident #35's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and was able to make herself understood and was able to understand others. The resident was edentulous. Her cognition was moderately impaired. On 03/25/24 at 11:53 A.M., an interview with Resident #35 revealed she lost her dentures prior to admission and wanted a new set. On 03/27/24 at 2:40 P.M., an interview…

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

Based on observation and staff interview, the facility failed to maintain resident care equipment and furnishings in a safe and sanitary condition. This affected two (Resident #10 and #26) of 24 residents reviewed. Findings include: 1. On 03/25/24 at 11:00 A.M., an observation of Resident #10's bedside table revealed the walnut colored laminate on the tabletop was peeling back leaving rough, jagged edges that was a potential hazard that could cause skin tears. There was also a couple areas where the particle board that was under the laminate was exposed preventing the bedside table from being able to be adequately disinfected when cleaning. Resident #10 was legally blind with macular degeneration and was not able to see the condition in which her bedside table was in. On 03/26/24 at 12:00 P.M., ongoing observations of Resident #10's bedside table revealed it remained in disrepair. The bedside table was placed next to the resident's bed on the left side and had items on top of it within the resident's reach. Findings were verified by Licensed Practical Nurse (LPN) #183. On 03/26/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident's Power of Attorney (POA) was provided with and signed an admission agreement upon the resident's admission into the facility that informed them of the resident's rights, services to the resident, and of the rules and regulations governing the resident's conduct and responsibilities during his stay in the facility. This affected one of one residents (#73) reviewed for the admission process. Findings include: A review of Resident #73's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included pneumoconiosis due to asbestos and other mineral fibers and alcohol abuse. His census revealed he was private pay hospice. A review of Resident #73's progress notes revealed he was admitted to the facility on [DATE] at 2:00 P.M. from inpatient hospice. The hospice nurse was in prior to the resident's arrival in the facility and stated the resident's family would be in to sign paperwork. The resident was 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.

Based on observation, review of narcotic inventory sheet, interview, and policy review the facility failed to ensure contingency narcotics were reconciled every shift. This had the potential to affect all 71 residents residing in the facility. Findings included: Observation and interview on 05/16/23 at 8:27 A.M., with LPN #123 revealed the contingency narcotic box was not doubled lock. The lock on the cabinet door was broke and the narcotic box was not affixed to the cabinet. The box had not been reconciled since 05/12/23 when it was delivered from the pharmacy. LPN #123 revealed she was not sure who was responsible for reconciliation of the narcotic box in the cabinet, however the 100-hall nurse was responsible for the narcotics in the refrigerator. The LPN confirmed the narcotic box had not been reconciled since 05/12/23 and the narcotics were not doubled locked nor affixed to the cabinet. Observation and Interview on 05/16/23 at 9:27 A.M., with LPN #131 (100-unit nurse) confirmed the contingency narcotic box had not been reconciled since 05/12/23 when pharmacy had delivered the…

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

Based on observation, review of narcotic inventory sheet, review of control sheets, interview, and policy review the facility failed to ensure medications were properly stored and labeled. This affected one resident (Resident #63) but had the potential to affect all 71 residents residing in the facility. Findings include: 1. Observation and interview on 05/16/23 at 8:27 A.M., with LPN #123 revealed the contingency narcotic box was not doubled lock. The lock on the cabinet door was broke and the narcotic box was not affixed to the cabinet. The LPN confirmed the narcotics were not doubled locked nor affixed to the cabinet. Observation and Interview on 05/16/23 at 9:27 A.M., with LPN #131 (100-unit nurse) revealed the narcotic box in the refrigerator contained 22 Marinol capsules that belonged to Resident #63 and the narcotic box was unlocked. The LPN reported the key for the refrigerator narcotic lock box had been missing for some time and the box wasn't locked. The LPN confirmed the medications were not doubled locked. The LPN also confirmed the cabinet lock had been broken for about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to adequately inform/specify in writing, the services that would be discontinued. This affected two residents (Resident #71 and Resident #72) of three resident beneficiary notices reviewed. The census was 71. Findings Include: 1. Resident #71 was admitted to the facility on [DATE]. His diagnoses were heart failure, cerebral infarction, type II diabetes, morbid obesity, obstructive sleep apnea, major depressive disorder, hypertension, atrial fibrillation, dementia, atherosclerotic heart disease, and facial weakness. Review of his minimum data set assessment, dated 04/18/23, revealed he had a significant cognitive impairment. Review of Resident #71 beneficiary notice form, dated 04/22/23, revealed a discontinuation of services would end on that day. But the form did not give specific information as to what services would be discontinued. The form stated, the effective date coverage of your current skilled nursing facility will end: 04/22/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two residents (Resident #21 and Resident #24) of three residents reviewed for PASRR documents. The census was 71. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, morbid obesity, nondisplaced fracture of greater trochanter of left femur, atrial fibrillation, major depressive disorder, atherosclerotic heart disease, hyperlipidemia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder (08/11/20), osteoarthritis, hypertension, and abnormal weight loss. Review of her Minimum Data Set (MDS) assessment, dated 02/06/23, revealed she was cognitively intact. Review of Resident #21 PASRR document, dated 07/07/21, revealed under Section D, the only diagnosis listed was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two residents (Resident #21 and Resident #24) of three residents reviewed for PASRR documents. The census was 71. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, morbid obesity, nondisplaced fracture of greater trochanter of left femur, atrial fibrillation, major depressive disorder, atherosclerotic heart disease, hyperlipidemia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder (08/11/20), osteoarthritis, hypertension, and abnormal weight loss. Review of her Minimum Data Set (MDS) assessment, dated 02/06/23, revealed she was cognitively intact. Review of Resident #21 PASRR document, dated 07/07/21, revealed under Section D, the only diagnosis listed was mood disorder. But review of her diagnoses…

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, interview and policy review, the facility failed to ensure nail care was provided to Resident #55, who was dependent on staff for personal hygiene. This affected one resident (Resident #55) of two residents reviewed for activities of daily living (ADLs). The facility census was 71. Findings included: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, anemia, chronic kidney disease, and diabetes mellitus. Review of the nursing progress notes, dated 01/26/23 through present, revealed no evidence that Resident #55 refused to have his finger nails trimmed. Review of the 5-Day Minimum Data Set (MDS) 3.0 assessment, dated 02/02/23 revealed Resident #55 had intact cognition and required extensive assistance of one staff for personal hygiene. The assessment indicated no behaviors or rejection of care. Review of the plan of care, dated 02/06/23,…

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, hospital record review, and interview the facility failed to timely provide intervention with a resident condition change resulting in hospitalization. This affected one resident (Resident #69) of one residents reviewed for hospitalization. The census was 71. Findings include: Closed record review revealed Resident #69 was admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, diabetes, emphysema, atrial fibrillation, heart failure, hypertension, atherosclerotic heart disease, and peripheral vascular disease. The resident was treated for pneumonia with antibiotics during his hospitalization and had been intubated and placed on a ventilator related to the acute respiratory failure with hypoxia (prior to his admission to the facility). The resident was discharged to the hospital on [DATE]. Review of the admission physician orders revealed Cefdinir (antibiotic) 300 milligrams twice a day for five days and azithromycin…

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, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when it was above to Medicaid allowable limit. This affected three residents (Residents #39, #48, and #49) of six resident financial information reviewed. The census was 71. Findings Include: 1. Resident #39 was admitted to the facility on [DATE]. Her diagnoses were unspecified injury of head, type II diabetes, asthma, cerebral infarction, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hyperlipidemia, major depressive disorder, hypertension, cerebral aneurysm, obesity, osteoarthritis, and repeated falls. Review of her Minimum Data Set (MDS) assessment, dated 03/06/23, revealed she mad a mild cognitive impairment. Review of Resident #39 quarterly financial statements, dated 07/01/22 to 03/31/23, revealed her total amount in her resident account varied between $3528.95 and $6526.46; it was never below $2000. Review of facility 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.

Based on observation, medical record review, review of drug inserts instruction sheet, interview, and policy review the facility failed to ensure the medication administration error rate was not greater than five percent. Two medication errors out of 32 opportunities were observed resulting in a 6.25% medication error rate. This affected two residents (Resident #24 and #31) of four residents observed for medication administration. Findings included: 1. Record review revealed Resident #24 was admitted to the facility with chronic respiratory failure. Review of Resident #24's orders dated 05/2023 revealed to administer one inhalation (puff) of Symbicort 90-4.5 micrograms (mcg) twice daily for chronic respiratory failure. Observation on 05/16/23 at 9:11 A.M., of medication administration with Licensed Practical Nurse (LPN) #131 revealed LPN #131 administered two inhalations of Symbicort to Resident #23 and then administered the resident her by mouth pills without having the resident rinse or spit after the administration of Symbicort. The label on the Symbicort indicated to administer…

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 policy review the facility failed to ensure medication and glucose monitoring were completed to maintain sanitary conditions to prevent the spread of infections. This affected one resident (Resident #47) of four observed for medication administration. Findings include: 1. Observation on 05/16/23 at 8:23 A.M., with Licensed Practical Nurse (LPN) #123 revealed the nurse had a multi-use glucometer lying on the medication cart without a barrier. The nurse reported the glucometer was used for residents in 400 and 500 halls. The nurse picked up the glucometer and carried it into Resident #47 room without cleaning the glucometer and laid it on the residents table without a barrier. The nurse checked the resident blood sugar and then placed the used glucometer in her shirt pocket and left the resident's room. The LPN performed hand hygiene and then disposed of the lancets. She removed the glucometer and wiped it with a bleach wipe and placed the glucometer in a plastic disposable cup. She did not keep the glucometer wet. The nurse reported the glucometer…

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, McGeer Criteria for Infection Surveillance Checklist review and interview, the facility failed to ensure antibiotics administered for a urinary tract infection (UTI) met criteria prior to the administration of the antibiotic. This affected one resident (Resident #28) of three residents reviewed for urinary tract infection. The facility census was 71. Findings include: Review of the Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, chronic obstructive pulmonary disease, diabetes mellitus, anemia, cirrhosis of the liver, chronic kidney disease, and a history of transient ischemic attacks and cerebral infarction. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 01/07/23, revealed the resident had moderately impaired cognition, required extensive, one-person physical assistance for bed mobility, transfers, dressing and toileting. The assessment indicated the…

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