Country Lane Gardens Rehab & Nursing Ctr

Inspectors wroteBased on observation, staff interview and review of facility policy the facility failed to dispose of expired medications and ensure medications were dated when opened. This had the potential to affect all residents residing at the facility. The facility census was 82.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to develop and implement comprehensive care plans to address identified resident needs and preferences. This affected four residents (#23, #6, #58, and #59) of 33 residents reviewed. The facility census was 82.

Inspectors wroteBased on observation, interview, medical record review, review of activities calendars, and review of facility policy, the facility failed to ensure activity preferences were available to aides and failed to complete activities according to preference for Resident #37, #59, #89, and #90. This affected four residents (#37, #59, #89, and #90) of four residents reviewed for activities. The facility census was 82.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to maintain a clean, sanitary environment free from pests. This had the potential to affect all 12 residents residing on the C hall. The facility census was 82.

Inspectors wroteBased on medical record review, interview and review of facility policy, the facility failed to timely review baseline care plans for one (Resident #8) of 33 reviewed. The census was 82.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to provide non pressure skin treatments as ordered for Resident #27 and #67. The facility also failed to accurately document the correct location for a skin alteration for Resident #67. This affected two (Resident #27 and #67) of two residents reviewed for non-pressure skin alterations. The facility census was 82.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure resident glasses were obtained in a timely manner. This affected one (Resident #58) of one resident reviewed for vision services. The census was 82. Findings Include:Resident #58 was admitted to the facility on [DATE]. His diagnoses were arthropathy, venous insufficiency, hypokalemia, epilepsy, hyperlipidemia, chronic pulmonary embolism, hypertension, anxiety disorder, major depressive disorder, vitamin D deficiency, vitamin B12 deficiency, dementia, muscle weakness, and insomnia. Review of his minimum data set (MDS) assessment, dated 12/22/25, revealed he was cognitively intact. Review of Resident #58 vision appointment documentation, dated 12/15/25, revealed he had a complete vision exam. Review of the recommendations/plan after this visit included Resident #58 needing new bifocals. [...]

Inspectors wroteBased on record review, interview and facility policy review the facility failed to document urine output and description each shift for one (Resident #5) of two reviewed for a urinary catheter. The facility census was 82.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure a speech therapy evaluation was completed for one, (Resident #03) and the facility failed to the facility failed to monitor fluid intake for one (Resident #09) who was on fluid restriction. This affected two residents (#03 and #09) of four reviewed for nutrition. The facility census was 82.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure trauma-informed care was implemented for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). This affected one resident (Resident #6) of eight residents reviewed for behavioral-emotional care. The facility census was 82.

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to provide medications as ordered for Resident #9. This affected one resident (#9) of five residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure physician oversight for medications prescribed from an outside prescriber for Resident #75 and to failed to ensure parameters were followed for blood pressure medications for Resident # 9 and Resident #29. This affected three Residents (#9, #29 and #75) of 7 reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on record review, review of pharmacy recommendations, interview, and policy review, the facility failed to ensure laboratory tests were completed as ordered and the physician was notified of incomplete laboratory tests. This affected one resident (Resident #89) of five reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure routine dental appointments occurred for all residents. This affected one (Resident #59) of one resident reviewed for dental services. The census was 82. Findings Include:Resident #59 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease, sleep apnea, lymphedema, anxiety disorder, hyperlipidemia, post traumatic stress disorder, bipolar disorder, hypertension, delusional disorder, paranoid personality disorder, insomnia, and irritable bowel syndrome. Review of her minimum data set (MDS) assessment, dated 12/18/25, revealed she was cognitively intact. Review of Resident #59's dental appointment records revealed she had an initial appointment completed on 12/04/24. [...]

Inspectors wroteBased on interview and record review the facility failed to implement antibiotic stewardship regarding antibiotic use. This affected one (Resident #8) of one resident reviewed for antibiotics. The facility census was 82.

Inspectors wroteBased on review of medical records, interviews with staff and the contracted psychiatric mental health nurse practitioner, review of facility self-reported incidents (SRIs), review of facility investigation documents, and review of facility policies and clinical protocols, the facility failed to ensure residents with a diagnosis of dementia and history of sexually inappropriate behaviors received adequate and effective behavioral health services to address their need for individualized interventions, monitoring, and supervision. [...]

Inspectors wroteBased on observation, medical record review, and staff, and resident interview, the facility failed to maintain a homelike environment for residents by ensuring the facility supplied sufficient hot water for resident bathing and laundry needs. This deficiency had the potential to affect all 81 residents residing in the facility. The census was 81.

Inspectors wroteBased on record reviews, interview, and facility policies review, the facility failed to ensure residents were not physically restrained. This affected one (#10) of three residents reviewed for abuse. The facility census was 84. Findings Include:Review of the medical record for the Resident # 10 revealed an admission date of 11/18/25. Diagnoses included Type II Diabetes, morbid obesity, bipolar disorder and depression. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] and discharged MDS dated [DATE] revealed Resident #10's brief interview of mental status (BIMS) was not recorded. Review of hospital documentation dated 11/22/25 revealed Resident #10 was alert and oriented three times (person, place and time). He used a walker and wheelchair to transport himself throughout the facility and required one person supervision for activities of daily living. [...]

Inspectors wroteBased on record reviews, interview, and facility policy reviews, the facility failed to notify the State Agency of an allegation of abuse. This had the potential to affect one resident (#10) of three residents reviewed for abuse. The census was 84. Findings Include: Review of the medical record for the Resident # 10 revealed an admission date of 11/18/25. Diagnoses included Type II Diabetes, morbid obesity, bipolar disorder and depression . Review of his admission Minimum Data Set (MDS) assessment dated [DATE] and discharged MDS dated [DATE] revealed Resident #10's brief interview of mental status (BIMS) was not recorded. Review of hospital documentation dated 11/22/25 revealed Resident #10 was alert and oriented three times (person, place and time). [...]

Inspectors wroteBased on record review, observations, and staff interview, the facility failed to ensure residents were free from significant medication errors when their full course of antibiotics would not be given. This affected two of three sampled residents (Residents #51 and #52). The census was 84. Findings Include:1. Review of the medical record for Resident #51 revealed an admission date of 07/21/25 and diagnoses including chronic obstructive pulmonary disease, morbid obesity, asthma, and chronic respiratory failure with hypoxia. Review of nursing progress notes revealed on 12/05/25 at 4:18 P.M. the resident was noted with cough/congestion this shift. Minimal relief from nebulizer treatments. Lungs with diminished bases bilaterally. Scattered rhonchi (sounds caused by constricted airways) noted throughout, some cleared with cough. Sputum light yellow to brown. [...]

Inspectors wroteBased on medical record reviews, review of self-reported incidents (SRI), interviews, and policy review the facility failed to implement their abuse policy to report an allegation of abuse accurately and in a timely manner for Resident #60. The facility also failed to thoroughly investigate an allegation of physical abuse between Resident #3 and #49. This affected three (Resident #3, #49, and #60) out of four residents reviewed for abuse. The facility census was 85.

Inspectors wroteBased on medical record review, review of self-reported incident (SRI), interviews, and policy review the facility failed to report an allegation of abuse immediately and accurately. This affected one (Resident #60) out of four residents reviewed for abuse. The facility census was 85.

Inspectors wroteBased on record review, review of self-reported incident (SRI), interviews, and policy review, the facility failed to thoroughly investigate an allegation of physical abuse between Resident #3 and #49. This affected two (Resident #3 and #49) out of four residents reviewed for abuse. Facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure a requested discharge process was completed timely and thoroughly. This affected two residents (Residents #44 and #82) of three residents reviewed for discharge process. The census was 85. Findings Include:1. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were anoxic brain injury, dementia, bipolar disorder, major depressive disorder, edema, post traumatic stress disorder, opioid use, anxiety disorder, anemia, insomnia, and nightmare disorder. Review of her minimum data set (MDS) assessment, dated 09/30/25, revealed she was cognitively intact. Review of Resident #44 progress notes, dated 09/30/25 to 10/16/25, revealed 13 different referrals were sent to other nursing facilities for the possible transfer/discharge of Resident #44. [...]

Inspectors wroteBased on record review, resident and staff interviews, review of facility policy, and review of the Ohio Administrative Code, the facility failed to ensure qualified personnel removed a midline intravenous (IV) catheter. This affected two (#22 and #49) of four residents reviewed with midline or peripheral intravenous central catheters (PICC). The facility census was 87.

Inspectors wroteBased on observation, record review, review of a facility timeline of events, review of hospital records and a physician after visit summary, facility policy review and interview, the facility failed to prevent an incident of neglect involving Resident #32. This resulted in Immediate Jeopardy and Actual Harm beginning on 09/19/25 at 10:30 A.M. when Resident #32, who was identified to have confusion and poor decision making, was left outside the facility in the sun with the air temperature between 82 and 85 degrees Fahrenheit unattended. On 09/19/25 at approximately 1:45 P.M. Resident #32 was found outside the facility unresponsive with a body temperature of 107 degrees (F) and an oxygen saturation level of 88 percent with resulting second degree burns/blisters on her arms and legs. [...]

Inspectors wroteBased on closed medical record review, hospital record review, death certificate review, facility policy and procedure review, facility assessment review, and interview, the facility failed to timely identify and provide comprehensive, resident centered interventions following an acute change in condition for Resident #95. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on 06/27/25 when Resident #95, who had severe cognitive impairment and required staff assistance with activities of daily living (ADL) was noted by staff to have an acute change in medical condition which included dusky colored hands and feet, limited food and fluid intake, lethargy, and the need for supplemental oxygen. There was no additional assessment of the resident's condition at that time or intervention provided. On 06/29/25 at 8:30 P.M. [...]

Inspectors wroteBased on record review, clinic note review, hospital record review and interview the facility failed to ensure Resident #79 was provided adequate and necessary comprehensive, resident centered care following a vascular procedure for arterial stenosis to prevent complications. [...]

Inspectors wroteBased on closed record review, hospital record review, interview and policy review the facility failed to provide a comprehensive, resident centered plan of care to prevent, timely identify, and treat weight loss and dehydration. This resulted in actual harm on 06/29/25 when Resident #95, who was identified at nutritional risk, was cognitively impaired and required staff assistance with activities of daily living (ADLs), was assessed by hospital staff to exhibit possible severe malnutrition and severe dehydration with a weight of 77 pounds. The most recent facility weight, documented on 06/25/25 was recorded to be 91 pounds. The facility failed to ensure effective, appropriate and sustainable interventions were in place to prevent the significant weight loss and severe dehydration resulting in hospitalization. [...]

Inspectors wroteBased on review of facility staffing reports, review of facility staff time punches and staff interviews, the facility failed to provide eight hours of consecutive Registered Nurse (RN) direct care and had the Regional Director of Nursing as providing resident care for three days reviewed in a seven-day (one week) period. This had the potential to affect all 94 residents living in the facility.

Inspectors wroteBased on record review, review of the facility assessment, review of the Administrator Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected four (#32, #51, #79, #81) of 17 sampled residents with the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on review of quality assurance/performance improvement (QAPI) minutes, review of the governing body, interviews, and policy review the facility failed to have an effective governing body to oversee the functions of the facility. This affected four (#32, #51, #79, #81) of 17 sampled residents with the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) minutes, review of policies, and interviews, the facility failed to ensure the medical director implemented resident care policies, coordinated medical care in the facility, and participated in QAPI meetings. This affected three (#40, #79, #95) of 17 residents reviewed during the course of the survey and affected all 94 residents residing in the facility due to the failure of the medical director fulfillment of his responsibilities.

Inspectors wroteBased on review of quality assurance/performance improvement (QAPI) minutes, interviews, and policy review the facility failed to have an effective QAPI program. This affected six (#3, #40, #51, #79, #81, #95) and of 17 residents reviewed during the course of the survey and all 94 residents residing in the facility.

Inspectors wroteBased on record review, observations, and staff interview, the facility failed to ensure resident records were complete and accurately documented. This affected four (#6, #40, #79, and #81) of 17 sampled residents. The facility census was 94.

Inspectors wroteBased on review of Resident Council Meeting Minutes and staff interview, the facility failed to act promptly upon the grievances concerning issues of resident care voiced by residents at resident council meetings. This affected nine (9) residents who attended the resident council meeting (Residents #7, #24, #49, #72, #74, #76, #80, #85, and #92). The facility census was 94.

Inspectors wroteBased on medical record review, policy review, staff interview, and family interview, the facility failed to notify the resident's representative when there was a significant change in the resident's physical status and when the resident was transferred to the hospital for treatment. This affected one (#32) of 17 sampled residents. The facility census was 94.

Inspectors wroteBased on observation, record review, review of controlled substance inventory count sheets, review of pharmacy proof of delivery reports, review of written staff statements, staff interview, resident interview, and policy review, the facility failed to prevent the misappropriation of resident property when a resident's narcotic pain medications were diverted and unaccounted for. This affected one (#51) of three residents reviewed for narcotic pain medications. The facility census was 94.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident was free from chemical restraints which were not required to treat a resident's medical symptoms. This affected one (#32) of 17 sampled residents. The facility census was 94.

Inspectors wroteBased on observation, record review, review of self-reported incidents (SRI), and staff interviews, the facility failed to report an allegation of missing narcotics. This affected two (#51, #81) of 17 sampled residents. The facility census was 94.

Inspectors wroteBased on review of medical records, staff interviews, policy review, and observation, the facility failed to ensure that residents on the locked unit were protected during the course of an investigation into resident to resident abuse. This affected one (#14) of three residents reviewed for abuse. The facility also failed to thoroughly investigate an allegation of missing narcotics. This affected two (#51, #81) of three residents reviewed for narcotic use. The facility census was 94.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This affected one (#51) of three residents reviewed for showers/bathing. The facility census was 94.

Inspectors wroteBased on record review, staff interview, and contract review, the facility failed to ensure ongoing communication and collaboration with a dialysis facility regarding dialysis care and services for a resident. This affected one (#40) of 17 sampled residents. The facility census was 94.

Inspectors wroteBased on review of the medical record and staff interviews, the facility failed to implement appropriate behavioral healthcare and interventions for a resident's behaviors. This affected one (#14) resident of three residents reviewed for behavioral services. The facility census was 94.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#3, #40) of 17 sampled residents. The facility census was 94.

Inspectors wroteBased on review of the medical record, policy review, and interview, the facility failed to notify physician and family of abnormal radiology results. This affected one resident (#14) of three residents reviewed for notification. The facility census was 89. Findings Include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and other toxic encephalopathy. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #14's cognition remained intact, and she had no behaviors. Review of nursing notes from 07/25/25 through 07/27/25 revealed no documented evidence of Resident #14 having a fall or being lowered to the ground. [...]

Inspectors wroteBased on closed medical record review, policy review and interview, the facility failed to provide timely diagnostic services and treatment when Resident #14 complained of pain to her ankle after a fall. This affected one resident (#14) of three residents reviewed for change in condition. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, non-facility staff interview, and facility policy review, the facility failed to ensure accurate/clear advanced directives were in place at the time of a resident's death. This affected one, (Resident #90), of three resident reviewed for advanced directives. The census was 88. Findings Include: Resident #90 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, waldenstrom macroglobulinemia, atrial fibrillation, dementia, dysphagia, schizophrenia, hypertension, anemia, catatonic disorder, restlessness and agitation, encounter for palliative care, hallucinations, psychosis, and colostomy status. Review of his minimum data set (MDS) assessment, dated [DATE], revealed he had a severe cognitive impairment. Review of Resident #90's physician orders found he was placed on hospice services on [DATE]. [...]

Inspectors wroteBased on medical record review, staff interview, non-facility staff interview, and facility policy review, the facility failed to ensure all resident medical records were complete. This affected one (Resident #90) of three resident medical records reviewed. The census was 88. Findings Include: Resident #90 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, waldenstrom macroglobulinemia, atrial fibrillation, dementia, dysphagia, schizophrenia, hypertension, anemia, catatonic disorder, restlessness and agitation, encounter for palliative care, hallucinations, psychosis, and colostomy status. Review of his minimum data set (MDS) assessment, dated [DATE], revealed he had a severe cognitive impairment. Review of Resident #90 progress notes, dated [DATE], revealed two notes that stated, expired and body released to funeral home. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure hospice records were in the facility for full access and review. This affected one, (Resident #90), of one resident reviewed for hospice services. The census was 88. Findings Include: Resident #90 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, waldenstrom macroglobulinemia, atrial fibrillation, dementia, dysphagia, schizophrenia, hypertension, anemia, catatonic disorder, restlessness and agitation, encounter for palliative care, hallucinations, psychosis, and colostomy status. Review of his minimum data set (MDS) assessment, dated 04/22/25, revealed he had a severe cognitive impairment. Review of Resident #90's physician orders found he was placed on hospice services on 05/01/25. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, resident and staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, review of the police report, policy review, and review of the Sexual Assault Nurse Examiner (SANE) exam, the facility failed to ensure a resident was free from sexual abuse. Actual Harm occurred to Resident #71 when Resident #88 sexually assaulted Resident #71, leaving Resident #71 with internal injuries after the sexual assault and psychosocial harm when Resident #71 had significant decline in her mental condition with increased anger, depression, and scared, disclosed a history of sexual trauma, and reported flashbacks, nightmares, and increased anxiety triggered by a male resident (Resident #88). The facility census was 85.

Inspectors wroteBased on interview and medical record review, the facility failed to care plan and document on Resident #43's behaviors and ensure the physician or Certified Nurse Practitioner (CNP) addressed his behaviors. This affected one resident (#43) of four residents reviewed for abuse. The facility census was 90.

Inspectors wroteBased on record review, interview, review of the Ohio Department of Health (ODH) Gateway and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse to the state agency. This affected two residents (#26 and #70) of four residents reviewed for sexual abuse. The facility census was 91.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected two residents (#26 and #70) of four residents reviewed for sexual abuse. The facility census was 91.

Inspectors wroteBased on record review, review of a self-reported incident (SRI), facility policy review, and interview, the facility failed to accurately and timely identify and address sexually oriented behaviors involving cognitively impaired residents (#71 and #32) to ensure the residents were able to consent to sexual activity and to prevent potential incidents of resident to resident sexual abuse. This affected two residents (#71 and #32) of four residents reviewed for sexual abuse. The facility census was 91.

Inspectors wroteBased on observation, medical record review, facility policy and procedure reviews and interviews, the facility failed to ensure Resident #9, who was identified as nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring of nutritional status, physician notification of diet changes and discharge from hospice services, and implementation of nutritional interventions to prevent weight loss and honor the resident's right for food preferences. [...]

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to ensure three residents (#9, #68, and #79) were seen by a physician as required every 30 days for the first 90 days then every sixty thereafter. This affected three of 23 sampled residents. Findings Include: 1. Review of the medical record for Resident #68 revealed an initial admission date of 07/12/23 with the diagnoses including chronic obstructive pulmonary disease (COPD), asthma, severe morbid obesity, cerebrovascular accident (CVA) with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal disorder, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anxiety disorder, diabetes mellitus, anemia, nicotine dependence, cardiac arrhythmia and pain in limb. [...]

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure enhanced barrier precautions were in place for residents with indwelling medical devices. This affected one resident (#59) of three residents reviewed for infection control. Additionally, the facility failed to ensure vaccination consents were fully completed, affecting two residents (#9 and #59) of five residents reviewed for vaccinations; and the facility failed to track infectious organisms. This had the potential to affect all 77 residents residing in the facility. The census was 77.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure residents were treated with dignity and clothed per their preference. This affected one resident (#59) of two residents reviewed for dignity. The facility census was 77.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure one residents (#68) was able to utilize her power wheelchair. This affected one of two residents reviewed for dignity. Findings Include: 1. Review of the medical record for Resident #68 revealed an initial admission date of 07/12/23 with the diagnoses including chronic obstructive pulmonary disease (COPD), asthma, severe morbid obesity, cerebrovascular accident (CVA) with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal disorder, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anxiety disorder, diabetes mellitus, anemia, nicotine dependence, cardiac arrhythmia and pain in limb. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure a physician, resident, or the resident's guardian were notified of changes in services and treatment. This affected one resident (#9) of one resident reviewed for hospice services. The facility census was 77.

Inspectors wroteBased on record review and interviews, the facility failed to follow up on one resident's (#68) report of missing personal items. This affected one of one resident reviewed for personal property. Findings Include: Review of the medical record for Resident #68 revealed an initial admission date of 07/12/23 with the diagnoses including chronic obstructive pulmonary disease (COPD), asthma, severe morbid obesity, cerebrovascular accident (CVA) with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal disorder, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anxiety disorder, diabetes mellitus, anemia, nicotine dependence, cardiac arrhythmia and pain in limb. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review the facility failed to ensure two residents, who were dependent on staff, were provided shaving of facial hair and nail care. This affected two residents (#59 and #62) of five residents reviewed for activities of daily living (ADL). Findings Include: 1. Review of the medical record for Resident #62 revealed an initial admission date of cerebrovascular accident with right sided hemiplegia, aphasia, dysphagia, diabetes mellitus, protein calorie malnutrition, congestive heart failure, anemia, obstructive and reflux uropathy, hyperlipidemia, major depressive disorder, hypertension, insomnia, chronic pain syndrome, dry eye syndrome and gastro-esophageal reflux disease. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to implement a treatment to and monitor an abrasion behind Resident #79's right ear. This affected one of one resident (#79) reviewed for skin conditions. Findings Include: Review of the medical record for Resident #79 revealed an initial admission date of 01/23/24 with the diagnoses including but not limited to chronic obstructive respiratory failure (COPD), acute and chronic respiratory failure with hypoxia, severe protein calorie malnutrition, emphysema, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, hyperlipidemia, bipolar disorder, sleep disorder, mood disorder, suicidal ideations, poisoning by drugs, medicaments and biological substances intentional self harm, nicotine dependence, palliative care and overactive bladder. Review of the incident report dated 05/17/24 at 1:10 P.M. [...]

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure residents had physician orders for safety/fall interventions including the use of a perimeter mattress. This affected one resident (#38), of the five residents reviewed for fall interventions.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement a physician ordered dressing change to bilateral nephrostomy tubes (a tube that drains urine from your kidney into a bag) upon readmission to the facility. This affected one resident (#27) of two residents reviewed urinary tract infection. Findings Included: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident's received medically-related social services to maintain the highest practicable psychosocial well-being. This affected one resident (#9) of one resident reviewed for receiving social services. The facility census was 77.

Inspectors wroteBased on record review and interview, the facility failed to ensure as needed pain medication had parameters in place. This affected one resident (#59) of two residents reviewed for pain. The facility census was 77.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored in a locked compartment. This affected one resident (#1) of 77 residents in the facility. Findings Include: On 06/27/24 at 2:28 P.M., during a search of Resident #1's room for her right wrist brace, a clear plastic cup of pudding was found with chunks of a crushed white pill in them by State Tested Nursing Assistant (STNA) #116 on top of Resident #1's dresser. On 06/27/24 at 2:43 P.M., interview with Registered Nurse (RN) #223 revealed Resident #1's medications are administered whole and not crushed. RN #223 revealed she was unsure where the cup of medication came from and what the medication was. [...]

Inspectors wroteBased on medical record review and interview the facility failed to ensure accurate and complete medical records in the area of nutritional supplement intake. This affected one resident (#79) of three residents reviewed for weight loss. Findings Include: Review of the medical record for Resident #79 revealed an initial admission date of 01/23/24 with the diagnoses including but not limited to chronic obstructive respiratory failure (COPD), acute and chronic respiratory failure with hypoxia, severe protein calorie malnutrition, emphysema, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, hyperlipidemia, bipolar disorder, sleep disorder, mood disorder, suicidal ideations, poisoning by drugs, medicaments and biological substances intentional self harm, nicotine dependence, palliative care and overactive bladder. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a communication process was in place with a hospice company resulting in Resident #9 having a delay in hospice services. This affected one resident (#9) of one resident reviewed for hospice. The facility census was 77.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents required antibiotics prior to administration of antibiotics. This affected two residents (#237 and #50) of six residents reviewed for antibiotic stewardship. The facility census was 77.

Inspectors wroteBased on observation, record review, interview with staff, interview with guardian and review of the facility Wandering, Unsafe Resident policy and procedure, the facility failed to provide adequate supervision and safety interventions to prevent Resident #61 from eloping from the facility secure care unit. This resulted in Immediate Jeopardy and the potential for serious harm, injury, death on 03/24/24 between approximately 4:30 P.M. and 5:40 P.M. when Resident #61, who had a legal guardian, had a known history of eloping from skilled nursing facilities (SNFs) and who made verbal threats to elope from the facility exited the facility without staff knowledge and remained missing overnight. On 03/25/24 at 7:00 A.M. [...]

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to notify Resident #61's primary care physician (PCP) of an elopement from the facility. This affected one resident (#61) of three residents for elopement. The facility census was 86. Findings Include: [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #2, who was dependent on staff for bathing received scheduled showers. This affected one resident (#2) of three residents reviewed for showers. The facility census was 86. Findings Include: Review of the medical record for Resident #2 revealed an initial admission date of 07/12/23 with diagnoses including chronic obstructive pulmonary disease, asthma, severe morbid obesity, cerebrovascular accident with left sided hemiplegia, protein calorie malnutrition, atrial fibrillation, major depressive disorder, gastro-esophageal reflux disease, hypertension, hyperlipidemia, cannabis use, obstructive sleep apnea, anemia, pain, nicotine dependence and diabetes mellitus. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #2 was timely and appropriately treated for a urinary tract infection (UTI). This affected one resident (#2) of two residents reviewed for UTI. The facility census was 86.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to ensure narcotic pain medication was available to administer to one resident (#34). This affected one (Resident #34) of three residents reviewed for pain. The facility census was 87. Findings Include: [...]

Inspectors wroteBased on review of witness statements and staff interview, the facility failed to thoroughly investigate Former Registered Nurse (RN) #122 working while suspected of being under the influence of alcohol in order to ensure the residents Former RN #122 was assigned to care for were not adversely affected or subject to any type of abuse, neglect or misappropriation as a result of the incident. This had the potential to affect all 22 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #36, #38, #40, #42, #45, #83) residing on Unit A and the even rooms in Unit C. The facility census was 78.

Inspectors wroteBased on medical record review, staff interview, and resident interview, the facility failed to ensure residents were bathed according to their preference. This affected one (Resident #2) out of the three residents reviewed for bathing.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to ensure shared glucometers (device used to determine a resident's blood glucose level by placing a drop of blood on a test strip and inserted into the glucose meter) were properly disinfected between uses. This affected four residents (Residents #6, #22, #25, and #32).

Inspectors wroteBased on observation and staff interview the facility failed to have a working call system from resident toilet rooms on the second floor. This had the potential to affect 30 of 30 residents who lived on the second floor (Resident #34, Resident #47, Resident #3, Resident #29, Resident #38, Resident #43, Resident #54, Resident #46, Resident #132, Resident #65, Resident #15, Resident #8, Resident #33, Resident #39, Resident #40, Resident #24, Resident #2, Resident #80, Resident #12, Resident #48, Resident #42, Resident #23, Resident #285, Resident #44, Resident #286, Resident #36, Resident #37, Resident #35, Resident #57, and Resident #66) of 86 residents who lived in the facility.

Inspectors wroteBased on review of state/federal economic stimulus information and Medicaid guidelines, resident medical record review, financial record review, staff interview, and facility policy review, the facility failed to ensure resident financial accounts were maintained within the appropriate limits. This affected three (Residents #11, #41 and #44) of six resident financial records reviewed. The census was 86. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident that utilizes Medicaid insurance may not keep more than $2000 in a trust account. Also, the same guidelines confirmed that the COVID-19 stimulus checks (three total) do not count as monthly income; so it would not affect a resident's medical coverage. [...]

Inspectors wroteBased on review of beneficiary notice documents and staff interview the facility failed to provide all the required notices to residents discharged from skilled nursing services, had not exhausted their benefits, and remained in the facility. This affected two (Resident #44, and Resident #59) of three sampled residents reviewed for beneficiary protection notification. The facility census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide the following information to the receiving entity; contact information of the practitioner responsible for the resident's care, contact information of the resident's representative, comprehensive care plan goals, and a discharge summary. This affected two residents (Resident #65 and Resident #82) of two sampled residents reviewed for facility initiated transfers. The facility census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the resident's representative in writing of discharge and the move and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. In addition, the resident's representative was not provided the reason for the discharge, the location of the discharge, the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman and for residents with mental disorders or related disability the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with mental disabilities. This affected two residents (Resident #65 and Resident #82) of two sampled residents reviewed for facility initiated discharge. The facility census was 86.

Inspectors wroteBased on review of medical records, staff interview and policy review, the facility failed to notify the resident or the resident's representative of the duration of the state bed hold policy and the facility's policies regarding bed-hold periods. This affected two residents (Resident #65 and Resident #82) of two sampled residents reviewed for discharge. The facility census was 86.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure comprehensive resident assessments were conducted every 12 months. This affected one resident (Resident #29) of 19 sampled residents whose comprehensive assessments were reviewed. The facility census was 86.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) Identification Screen was completed for residents who had a newly added serious mental illness diagnosis. This affected two (Resident #25 and #65) of six residents reviewed for PASARR).

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to notify the state mental health authority promptly after residents had a significant change in their mental condition/ newly added diagnosis of a serious mental illness. This affected two (Resident #25 and #65) of six residents reviewed for Preadmission Screening and Resident Review (PASARR).

Inspectors wroteBased on medical record review, policy review, and staff interview, the facility failed to complete a recapitulation of an anticipated discharge of a resident. This affected one resident (Resident #84) of one sampled resident reviewed for an anticipated discharge. The facility census was 86.

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#5), who was dependent on staff received nail care. This affected one of three residents reviewed for activities of daily living (ADL). Findings Included: Review of Resident #5's medical record revealed an admission date of 01/22/16 with the admitting diagnoses of Parkinson's disease, rheumatoid arthritis, diabetes mellitus, hypertension, hyperlipidemia, psychosis, major depressive disorder, overactive bladder, mood disorder, anxiety disorder, dry eye syndrome, vitamin B deficiency, niacin deficiency, Vitamin D deficiency, thiamine deficiency, constipation, pain, restless leg syndrome, insomnia and gastro-esophageal reflux disease. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure one resident (#21) vascular wounds were initially assessed and subsequently assessed weekly. This affected one of three residents reviewed for skin conditions. Findings Include: Review of Resident #21's medical record revealed an initial admission date of 10/25/19 with the latest readmission of 02/23/22. Diagnoses included chronic obstructive pulmonary disease (COPD), atrial fibrillation, asthma, hypertension, congestive heart failure, severe morbid obesity, obstructive sleep apnea, osteoarthritis, shared psychotic disorder, major depressive disorder, hypothyroidism and history of COVID-19. Review of the nursing admit/readmit date d 02/23/22 revealed the vascular wounds were not present on admission. [...]

Inspectors wroteBased on record review, review of consultation reports from a wound consultant, staff interview and policy review, the facility failed to assess a resident's pressure ulcers weekly to monitor the progression of the wound healing. This affected one (Resident #64) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to adequately monitor significant weight loss and meal intakes. This affected one (Resident #72) of four residents reviewed for nutrition. The census was 86. Findings Include: Record review revealed Resident #72 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, chronic obstructive pulmonary disease, acute and chronic respiratory failure, acute embolism and thrombosis, asthma, morbid obesity, single subsegmental pulmonary embolism, anemia, hypertension, atrial fibrillation, tremor, sleep apnea, and encephalopathy. Review of her Minimum Data Set (MDS) 3.0 assessment, dated 04/02/22, she was deemed to be cognitively intact. Review of Resident #72 medical records revealed the following weights: [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview the facility failed to provide medically related social services to assist a resident in identifying alternative housing options and assistance with legal issues. This affected one resident (Resident #29) of three sampled residents reviewed for discharge. The facility census was 86.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure pharmacy recommendations were responded to timely by the physician and the physician provided an appropriate rationale as to why the pharmacy recommendation was contraindicated. This affected three (Resident #5, #16 and #65) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to provide adequate justification for the use of psychotropic medications. This affected two (Residents #285 and #5) of five residents reviewed for unnecessary medications. In addition, the facility failed to adequately address the use of as needed medications. This affected one (Resident #65) of five residents reviewed for unnecessary medications. The census was 86. Findings Include: 1. Record review revealed Resident #285 was admitted to the facility on [DATE]. His diagnoses were encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, acute and chronic respiratory failure, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, tobacco use, unspecified dementia with behavioral disturbance. His cognitive assessment had not been completed. [...]

Inspectors wroteBased on record review, observation, review of the manufacturer's product information, staff interview, and policy review, the facility failed to ensure their medication error rate was less than 5%. The facility had two errors out of 25 opportunities for errors for a medication error rate of 8%. This affected two (Resident #32 and #284) of four residents observed for medication administration observation.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered by the physician. This affected one (Resident #16) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure justification of antibiotic use for three residents (#14, #48 and #49). This affected three of three reviewed for antibiotic use. Findings Include: 1. Review of Resident #48's medical record revealed an initial admission date of 09/01/18 with the latest readmission of 10/07/18 with the admitting diagnoses of polyarthritis, congestive heart failure, hypertension, hypothyroidism, insomnia and history of COVID-19. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had a severe cognitive deficit as indicated by a BIMS score of three. [...]

Inspectors wroteBased on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the staff vaccination tracker, review of the COVID tracking log, review of staff schedules, review of timecards, review of the facility policy and interviews, the facility failed to implement their policy to ensure the staff COVID-19 vaccination rate was 100%. The facility staff vaccination rate was 96.03%. The census was 86.