Gardens of Mayfield Village

Inspectors wroteBased on observation, record review and interview the facility failed to honor Resident #24's food preferences and failed to ensure the food items served for meals were consistent with the planned four-week menu. This affected one resident (Resident #24) out of three residents reviewed for food preferences and had the potential to affect all the residents in the facility. The facility census was 55.

Inspectors wroteBased on record review and interview the facility failed to provide Resident #32's guardian with the results of the investigation of Resident #32's allegation of abuse in a timely manner. This affected one out of three residents reviewed for allegations of abuse. The facility census was 55.

Inspectors wroteBased on record review and interview the facility failed to maintain a complete accurate medical record for Resident #32. This affected one out of three residents reviewed for abuse. The facility census was 55.

Inspectors wroteBased on observation, interview and review of facility policy, the facility did not ensure a comfortable environment for Resident #24. This affected one resident (#24) of three residents interviewed for physical environment and had potential to affect an additional 24 residents (#7, #11, #13, #14, #19, #21, #23, 25, #28, #29, #31, #34, #35, #38, #40, #41, #44, #45, #47, #50, #53, #57, #58 and #59 residing on the second floor. The facility census was 63.

Inspectors wroteBased on record review, observation, interview, and review of facility policy, the facility did not ensure Resident #63's urinary catheter device was properly secured. This affected one resident (#63) of two residents reviewed for urinary catheters. The census was 63.

Inspectors wrote3. Review of Resident #8's medical records revealed an admission date of 02/13/25 with diagnoses including bilateral lower extremity ulcers and pressure ulcer of the left heel. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 required maximum (staff) assistance with bathing and personal hygiene. Review of care plan dated 04/23/25 revealed Resident #8 had a pressure ulcer to the left heel. Interventions included administer treatments as ordered. Review of physician orders for May 2025 revealed Resident #8 was ordered to cleanse left heel with normal saline, apply collagen (wound dressing used to promote healing), cover with an absorbent pad and wrap with gauze daily and as needed. Interview on 05/12/25 at 12:40 P.M. [...]

Inspectors wrote4. Review of Resident #60's medical records revealed an admission date of 01/21/25. Diagnoses included dementia, muscle weakness and need for personal care assistance. Review of care plan dated 04/23/25 revealed Resident #60 resided on the secured unit related to decreased safety awareness. Resident #60 was a smoker. Interventions included instruct resident on the facility policy on smoking and notify charge nurse if it is suspected resident had violated smoking policy and Resident #60 required supervision while smoking. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had intact cognition. Review of smoking assessment dated [DATE] revealed Resident #60 was safe to smoke with supervision. Review of progress note dated 04/30/25 timed 12:24 P.M. authored by Licensed Practical Nurse (LPN) #108 revealed Resident #60 had been suspected of smoking in his room. [...]

Inspectors wroteBased on personnel file review, interview, and review of facility policy, the facility did not ensure staff hired were free of disqualifying offenses. This affected two out of 11 personnel files reviewed for background checks and had the potential to affect all 59 residents in the facility.

Inspectors wroteBased on personnel file review, interview, and review of facility policy, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry and ensuring all staff received a background check prior to employment This affected seven out of 11 personnel files reviewed for nurse aide registry checks and had the potential to affect all 59 residents in the facility.

Inspectors wroteBased on observation, review of facility cleaning logs, and interviews, the facility failed to ensure the kitchen was maintained in a clean sanitary manner. This had the potential to affect all residents receiving food from the kitchen. The facility identified one resident (Resident #34) who received nothing by mouth. The facility census was 59.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) committee identified and followed through on concerns timely. This had the potential to affect all 59 residents in the facility.

Inspectors wrote2. Review of Resident #9's medical records revealed an admission date of 04/09/25. Diagnoses included infection related to indwelling urethral catheter, neuromuscular bladder and need for personal care assistance. Review of care plan dated 04/14/25 revealed Resident #9 had an indwelling urinary catheter. Interventions included monitor for signs and symptoms urinary tract infection that included cloudiness, foul smelling urine and deepening of urine color. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had an indwelling urinary catheter. Review of physician orders for May 2025 revealed Resident #9 was on enhanced barrier precautions (EBP) related to indwelling medical device. Observation on 05/14/25 at 7:49 A.M. revealed Resident #9 was sleeping in bed and the urinary catheter bag was observed on the floor under Resident #9's bed. [...]

Inspectors wroteBased on record review, review of Centers for Disease Control and Prevention (CDC) guidance and interview the facility failed to ensure residents were screened for immunization, educated on the risk and benefit of receiving the COVID-19 vaccine, or were offered and received COVID-19 vaccinations as required. This affected five residents (#3, #8, #11, #21 and #60) of five reviewed for vaccinations. The facility census was 59.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure the elevators were working in a safe operation condition. This had the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, sanitary and safe environment. This had the potential to affect all 59 residents residing in the facility. The facility census was 59.

Inspectors wroteBased on observation and interview, the facility failed to maintain resident room water temperatures at a comfortable level. This affected five (Residents #7, #19, #27, #32 and #49) out of seven resident rooms tested for water temperatures. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehension assessments were accurately completed. This affected five (Residents #34, #39, #51, #59 and #69) out of 40 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 59.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure dependent residents were assisted with activities of daily living. This affected four (Residents #21, #24, #39 and #51) of nine reviewed for activities of daily living for dependent residents. The facility census was 59.

Inspectors wroteBased on record review, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview the facility failed to ensure residents were were offered, screened, educated and received influenza and pnuemociccal vaccinations as required. This affected five residents (#3, #8, #11, #21 and #60) of five reviewed for vaccinations with the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on record review, policy review, and interview, the facility did not ensure Resident #26 was assessed to self-administer medications. This affected one resident (Resident #36) of two residents reviewed for self-administering medications. Facility census was 59.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a properly functioning elevator to accommodate resident needs. This affected three (Residents #6, #11 and #35) of 20 residents reviewed for environmental accommodation of needs. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received complete and accurate notices of Medicare non-coverage when their skilled services ended. This affected one (Resident #59) of four residents reviewed for liability notices. The facility census was 59.

Inspectors wroteBased on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to prevent staff-to-resident physical abuse. This affected one resident (#49) out of seven residents reviewed for abuse. Facility census was 59.

Inspectors wroteBased on interviews and record review the facility failed to ensure that as needed psychotropic medication orders were limited to 14 days for Resident #4. This affected one resident (Resident #4) out of five residents reviewed for unnecessary medications. The facility census was 59.

Inspectors wroteBased on record review, review of self-reported incidents (SRIs), interview and review of the facility policy, the facility failed to timely report allegations of abuse. This affected three residents (#6, #25 and #49) of seven residents reviewed for abuse. Facility census was 59.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse. This affected one resident (#49) of seven residents reviewed for abuse. Facility census was 59.

Inspectors wrote2. Review of Resident #49's medical record revealed an admission date of 02/20/25 and diagnoses including schizoaffective disorder, anxiety, depression, anemia and post-traumatic stress disorder. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact, had disorganized thinking, had an ostomy and was frequently incontinent of urine. Review of a plan of care dated 02/25/25 revealed Resident #49 had an alteration in gastrointestinal status related to ostomy. Interventions were listed including: Avoid lying down for at least one hour after eating; Keep head of bed elevated; Encourage to stand/sit upright after meals; Discuss with the resident/family/caregivers any concerns/fears/issues related to gastro-intestinal distress; Empty ostomy every shift and as needed (PRN); [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure showers were completed as scheduled and per resident preference. This affected two (Residents #27 and #59) out of two residents reviewed for showers who required less than or equal to limited assistance. The facility census was 59.

Inspectors wrote2. Review of Resident #48's medical records revealed an admission date of 01/30/25. Diagnoses included cognitive deficits, schizoaffective and bipolar. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition. Review of progress note dated 05/02/25 timed 10:30 P.M. authored by Registered Nurse (RN) #156 revealed Resident #48 had returned from the hospital with diagnoses of aggressive behaviors. No progress note had been authored prior to Resident #48's hospital discharge and no change in condition assessments had been documented. Interview on 05/20/25 at 12:35 P.M. with [NAME] President of Operations (VPO) #172 and Regional Registered Nurse (RRN) #182 revealed if a resident had a change in condition a change in condition assessment should be documented as well as a progress note. [...]

Inspectors wroteBased on medical record review, review of ancillary appointments and interviews, the facility failed to coordinate a follow up vision appointment for Resident #27 as required. This had the potential to affect one resident (Resident #27) of two residents reviewed for vision.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate catheter care and positioning of a urinary catheter bag. This affected one resident (#9) of one observed for catheter care. The facility census was 59.

Inspectors wroteBased on interview, observation and record reviews, the facility failed to implement nutritional intervention to address a significant weight change for Resident #62. This affected one resident (Resident #62) of one reviewed for nutrition. Facility census was 59.

Inspectors wroteBased on observation, record review, interview, and facility policy, the facility failed to ensure Resident #165's respiratory status was properly monitored and oxygen was administered per physician orders. This affected one resident (Resident #165) of two residents reviewed for respiratory services.

Inspectors wroteBased on the medical record review, physician visit records and interviews, the facility failed to ensure physician visits were provided as required for Resident #34. This had the potential to affect one resident (Resident #34) of 40 residents reviewed for physician services.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and administered as ordered. This affected one (Resident #51) of five residents reviewed for medications received from the pharmacy. The facility census was 59.

Inspectors wroteBased on interview, record review and review of the facility policy, the facility failed to timely address pharmacy recommendations. This affected two residents (#11 and #51) of five residents reviewed for unnecessary medications. Facility census was 59.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure medication error rate was less than five percent. There were a total of 26 medication opportunities observed with two medication errors resulting in a 7.69% medication error rate. This affected one (Resident #55) out of two residents observed for medication administration. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #51's laboratory testing was completed as ordered. This affected one (Resident #51) of four residents reviewed for laboratory orders. The facility census was 59.

Inspectors wroteBased on medical record review, dietary tray ticket review and interview, the facility failed to ensure resident preferences were honored and updated as required for Resident #27. This affected one resident (Resident #27) of five residents reviewed for food. The facility census was 59.

Inspectors wrote2. Review of the medical record for Resident #27 revealed an admission date of 05/01/24. Review of the diagnoses included but were not limited to adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia and depression. Review of the 05/09/25 annual Minimum Data Set (MDS) 3.0 for Resident #27 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Resident #27 was noted to require moderate assistance from staff for bathing, dressing, and personal hygiene. Review of the nursing progress note dated 04/05/25 revealed Resident #27 was given two tablets of 500 milligram (mg) of Tylenol for pain in her right knee. Review of the nursing progress note dated 04/09/25 timed at 12:10 A.M. revealed Resident #27 was given two 500 mg of Tylenol for leg pain that was not relieved by repositioning. [...]

Inspectors wrote8. Review of Resident #53's medical record revealed an admission date of 01/24/24 and diagnoses including type two diabetes, morbid obesity, non-pressure chronic ulcer of left heel and midfoot, arthritis and atrial fibrillation. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact, required staff set-up for activities of daily living and did not reject care. Review of Resident #53's physician's orders relative to wound care as of 05/14/25 revealed an order dated 01/14/25 for wound type and site sub fifth MTH left lower extremity cleanse with normal saline, apply alginate, maintain affixed padding with pad edges against the wound edges and cover with ABD pad then wrap with kerlex daily and as needed (PRN) every day shift every Tuesday, Thursday Saturday for treatment; [...]

Inspectors wroteBased on record review and interview, the facility failed to coordinate Resident #39's care and services with hospice to ensure continuity of care. This affected one resident (Resident #39) of one resident reviewed for hospice.

Inspectors wrote4. Review of Resident #1's medical record revealed an admission date of 03/27/20 and diagnoses including paraplegia, moderate protein-calorie malnutrition, hemiplegia and hemiparesis, depression, hypertension, constipation and dementia without behavioral disturbance. Review of Resident #1's census data revealed hospitalizations on 12/17/23, 08/27/24, 12/23/24, 12/31/24 and 05/08/25. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment, required set up for eating and was dependent on staff for most other activities of daily living. Review of eInteract assessments for Resident #1 revealed transfers to the hospital on [DATE] (nephrostomy malfunction) and 05/08/25 (nephrostomy and suprapubic catheters non-functioning). Interview on 05/22/25 at 7:40 A.M. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to complete care conferences in a timely manner for Resident #25, #35, #40, and #63. This affected four residents (#25, #35, #40, and #63) of four residents reviewed for care conferences. The facility census was 71.

Inspectors wroteBased on interview and record review, the facility failed to accurately document medication administration for Resident #18, enteral feedings for Resident #69, and make available for review controlled medication disposition records for Residents #18, #22 and #43. This affected four residents (#18, #22, #43 and #69) out of 19 medical records reviewed and had the potential to affect all 71 residents residing in the facility. There were 16 residents who received controlled medications (#1, #7, #12, #18, #22, #28, #38, #40, #41, #43, #44, #51, #56, #58, #60 and #61) and four residents who received enteral feedings (#13, #22, #41 and #69).

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to initiate and provide adequate individualized wound care and administer medications as ordered by the physician. This affected two residents (#36 and #40) of two residents reviewed for wound care and four residents (#18, #25, #30 and #63) of seven residents reviewed for medication administration. The facility census was 71.

Inspectors wroteBased on medical record review, review of the facility's fall investigations and incident reports, staff interview, and review of the facility's fall policy, the facility failed to conduct a thorough investigation after falls occurred and failed to implement appropriate interventions after a fall. This affected three residents (#31, #40, and #66) of three residents reviewed for falls. The facility census was 71.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure residents were seen by a general physician or nurse practitioner at least once every 60 days. This affected two residents (#16 and #51) of three residents reviewed for physician visits. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, facility policy review, review of manufacturer instructions, and review of the Food and Drug Administration (FDA) database of licensed biological products, the facility failed to be free of a five percent or greater medication error rate. This affected one resident (#2) of five residents (#1, #2, #22, #32 and #46) observed for medication administration. [...]

Inspectors wroteBased on observation, interview, record review, facility policy review, review of manufacturer instructions, and review of the Food and Drug Administration (FDA) database of licensed biological products, the facility failed to prevent a significant medication error for Resident #2 when insulin was inappropriately administered, and a medication was administered using the wrong dose and route. This affected one resident (#2) of five residents observed for medication administration. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to have survey results readily accessible to residents. This had the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized nutrition program to monitor, ensure nutritional recommendations were implemented and prevent weight loss for Resident #27 who was admitted to the facility with a new gastrostomy tube/enteral feedings. This affected one resident (#27) of five residents who were identified as receiving parenteral nutrition in the facility. The facility census was 74. Actual Harm occurred on 03/01/24 when Resident #27, who received parenteral nutrition (nutrition given via a feeding tube inserted into the abdomen due to an inability to take in adequate nutrients orally) was identified to have a severe weight loss. On 01/26/24 the resident's admission weight was documented to be 145 pounds. [...]

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to provide clean shower rooms for resident use. This had the potential to affect all residents. The facility also failed to provide a clean privacy curtain for two residents (#11 and #12) of 74 residents reviewed for environment. The facility census was 74.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to provide incontinence care in a dignified manner to Residents #33 and #48. This affected two residents (#33 and #48) of 48 residents who were identified as needing assistance with incontinence care. The facility census was 74.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed respond to Resident #48's needs in a timely manner. This affected one resident (#48) of 74 residents observed for call light response. The facility census was 74.

Inspectors wroteBased on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH (Nursing Home), staff interview, and facility policy review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) protocols. This affected two residents (#44 and #48) of 14 residents reviewed and identified as being on EBP. The facility census was 74.

Inspectors wroteBased on observation, interview, and meal service times review, the facility failed to serve lunch in a timely manner. This affected 71 residents receiving meals from the facility. The facility identified three residents (#27, #40, and #44) as receiving nothing by mouth. The facility census was 74.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to provide comprehensive, individualized and necessary diabetic ulcer (wound that commonly appears on the feet as a complication of diabetes often from lack of sensation or blood flow) assessment and care for Resident #151. This affected one resident (#151) out of three residents reviewed for diabetic/vascular/ pressure related wound care. The facility identified six residents (#111, #150, #151, #154, #162, and #163) with pressure/ vascular/ diabetic wounds. Actual harm occurred on 05/08/24 when the facility failed to adequately assess and implement diabetic ulcer wound care for Resident #151, a new admission who had intact cognition and was dependent on staff with activities of daily living (ADL) including bed mobility and transfers. [...]

Inspectors wroteBased on interview, observation, record review and review of the facility policy, the facility failed to ensure Residents #142 and #154 were free of significant medication errors. This affected two residents (#142 and #154) out of five residents observed for medication administration. The facility census was 68.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, review of an ambulance run report and interview with the local assistant fire chief, the facility failed to ensure bariatric mechanical lifts were available to assist residents with transfers. This affected three (#9, #19 and #58) of three residents reviewed for mechanical lifts. Additionally, the facility failed to ensure residents had appropriately fitting beds and mobility assistance equipment. This affected one (#9) of three residents reviewed for bed equipment and mobility needs. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/25/24. Diagnoses included type II diabetes, paraplegia, obesity and fusion of the spine. Further review revealed Resident #9 was six feet three inches tall and weighed 300 pounds. [...]

Inspectors wroteBased on medical record review, observation, staff interview, review of mechanical lift manufacturer's instruction and review of facility policy, the facility failed to ensure staff were properly trained to safely transfer residents utilizing mechanical lifts. This affected one (#58) of three residents reviewed for transfers. The facility identified 13 residents requiring a mechanical lift for transfer. The facility census was 64.

Inspectors wroteBased on observation, staff interview, medical record review and review of work orders, the facility failed to ensure the environment was adequately maintained. This affected three (#49, #55 and #58) of five residents reviewed for environmental concerns. The facility census was 64.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of an in-house acquired pressure ulcer for Resident #49. This affected one resident (#49) of three residents reviewed who were at risk for pressure ulcers. The facility census was 58. Actual Harm occurred on 03/26/24 when Resident #49, who was cognitively impaired and dependent on staff for mobility was found to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible and bone, tendon or muscles is not exposed. Slough may be present) pressure ulcer to the left buttock measuring 0.8 centimeters (cm) length by 1.5 cm width with 0.3 cm depth and serosanguineous drainage. The resident reported pain to the area. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a clean and sanitary environment. This affected four (#15, #46, #48 and #58) of six residents whose rooms were observed. The facility census was 58.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to ensure residents/resident representative participated in care planning. This affected three residents (#39, #48 and #49) of three reviewed for care conferences.

Inspectors wroteBased on observation, and interview the facility failed to ensure call lights were within reach and accessible for residents. This affected one (Resident #46) of six residents observed for call light placement. The facility census was 58.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to ensure timely incontinence care was provided and failed to ensure adequate care of a suprapubic urinary catheter. This affected one resident (#46) of three residents observed for incontinence care and one resident (#15) of two residents observed for suprapubic catheter care. The facility census was 58.

Inspectors wroteBased on observation, interview and review of facility policy the facility failed to ensure insulin vials were dated after opening. This affected one resident (#2) of two residents reviewed who received insulin. The facility census was 58.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate documentation of narcotics in the electronic medical records. This affected one resident (#2) of three residents reviewed for documentation. The facility census was 58.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure appropriate infection control techniques were used during and after insulin administration. This affected one resident (#2) of one resident observed for insulin administration. The facility census was 58.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 51 residents receiving meals from the kitchen. The facility identified three residents (#24, #30, and #33) who received enteral nutrition and did not receive meals from the kitchen. The facility census was 54. Findings Include: Observation during the initial kitchen tour on 03/04/24 from 8:52 A.M. till 9:07 A.M. with [NAME] #377 revealed the following concerns: • The handwashing sink did not have paper towels to dry hands. • An open case of mixed vegetables was untied with vegetables exposed to open air in the freezer. • A 10-pound tube of ground beef was thawed on a tray dated 02/22/24 with substantial blood surrounding the tube on the sheet pan in the refrigerator. [...]

Inspectors wroteBased on review of facility spreadsheets, observation, staff interview, and facility policy review the facility failed to ensure the correct portion size of ham was provided for 40 residents provided a regular diet. The facility identified eight residents (#5, #29, #35, #38, #42, #48, #52, and #53) receiving a mechanical soft diet, three residents (#15, #28, and #34) receiving a pureed diet and three residents (#24, #30 and #33) receiving nothing by mouth. The facility census was 54. Findings Include: Review of the facility menu for week two revealed on Monday the lunch meal was to consist of a turkey open faced sandwich, four ounces of mashed potatoes, four ounces buttered peas, one dinner roll, and four ounces of pineapple tidbits. Observation in the kitchen on 03/04/24 at 11:13 A.M. revealed ham slices were the main entrée and green beans were the vegetable. [...]

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure proper hand hygiene, glove use, and infection control barriers were utilized during wound care for Resident #13, and the facility failed to ensure proper hand hygiene materials were available during meal pass. This affected one resident (#13) of three residents reviewed for wound care and had the potential to affect 12 residents (#21, #22, #23, #25, #27, #28, #29, #30, #31, #32, #33, and #34) residing on the hallway for rooms 262 to 273. The facility identified one resident (#24) on the hallway as not receiving food by mouth. The facility census was 54. Findings Include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/24/23. Medical diagnoses included local infection of the skin and subcutaneous tissue, osteomyelitis, paraplegia, and multiple sclerosis. [...]

Inspectors wroteBased on record review, interview, and policy review the facility failed to follow physician ordered wound care for Resident #13 and Resident #56. This affected two residents (#13 and #56) of three residents reviewed for wound care. The facility census was 54. Findings Include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/24/23. Medical diagnoses included local infection of the skin and subcutaneous tissue, osteomyelitis, paraplegia, and multiple sclerosis. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact, utilized an indwelling urinary catheter and was frequently incontinent of bowel. Resident #13 had one unhealed stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure drinking water was within reach for hydration for Resident #5. This affected one resident (#5) of seven residents reviewed for hydration. The facility census was 54. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 01/20/21. Diagnoses included amyotrophic lateral sclerosis, moderate protein calorie malnutrition, chronic respiratory failure with hypoxia, emphysema, type II diabetes mellitus, dysphagia following cerebrovascular disease, encounter for gastrostomy, and anxiety disorder. Review of 12/24/23 quarterly Minimum Data Set (MDS) assessment for Resident #5 revealed a Brief Interview of Mental Status (BIMS) score of 14 of 15 which indicated the Resident #5 was cognitively intact. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure call lights were within reach for Resident #5. This affected one resident (#5) of six residents reviewed for call lights. The facility census was 54. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 01/20/21. Diagnoses included amyotrophic lateral sclerosis, moderate protein calorie malnutrition, chronic respiratory failure with hypoxia, emphysema, type II diabetes mellitus, dysphagia following cerebrovascular disease, encounter for gastrostomy, and anxiety disorder. Review of 12/24/23 quarterly Minimum Data Set (MDS) assessment for Resident #5 revealed a Brief Interview of Mental Status (BIMS) score of 14 of 15 which indicated the Resident #5 was cognitively intact. [...]

Inspectors wroteBased on observation, staff interview, and facility policy, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition and proper hand washing was being performed by dietary staff. This had the potential to affect 49 residents receiving food from the kitchen. The facility identified Residents #11 and #18 as receiving no food from the kitchen. The facility census was 51.

Inspectors wroteBased on review of facility spreadsheets, observation, staff interview, the facility failed to serve the correct portion size of fried rice was provided for 45 residents on a regular and mechanical soft consistency diets. The facility identified four residents (#5, #15, #23, and #35) as being on a pureed diet and two residents (#11 and #18) as receiving nothing by mouth. The facility census was 51.

Inspectors wroteBased on observation, staff interview, and facility policy, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition and proper hand washing was being performed by dietary staff. This had the potential to affect 49 residents receiving food from the kitchen. The facility identified Residents #11 and #18 as receiving no food from the kitchen. The facility census was 51.

Inspectors wroteBased on observation and interview the facility did not ensure food was served at a palatable temperature. This had the potential to affect the 56 residents who received meals prepared by the kitchen. The facility identified three residents (#18, #49 and #57) as receiving no food from the kitchen. The facility census was 59.

Inspectors wroteBased on observation and interview the facility did not ensure food items were labeled and dated and failed to ensure preparation equipment and surrounding areas were kept clean and sanitary. This had the potential to affect the 56 residents who received meals prepared by the kitchen. The facility identified three residents (#18, #49 and #57) as receiving no food from the kitchen. The facility census was 59.

Inspectors wroteBased on observation and interview the facility did not maintain the dumpsters in a manner to prevent pests. The lids were left open on all three dumpsters. This had the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have the required members, Infection Preventionist (IP) #374, attend the quarterly Quality Assessment and Assurance (QAA) meetings. This had the potential to affect all residents. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure state-tested nursing aides (STNAs) received twelve hours of annual in-service training. This affected two STNA's (#353 and #325) of seven employees reviewed for personnel requirements and had the potential to affect all 59 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the residents' status. This affected one resident (#2) of 23 residents whose MDS assessments were reviewed. The facility census was 59.

Inspectors wroteBased on interview and record review the facility failed to develop care plans related to methadone use, pancreatic insufficiency, and constipation/impaction/chronic colonic dilatation. This affected one resident (#44) of five residents reviewed for care plans. The facility census was 59.

Inspectors wroteBased on the observation, record review, and interview, the facility failed to ensure care plans were revised to include Resident #3 had a stage III pressure ulcer on his right posterior ear and Resident #22 self-managed his CPAP (continuous positive airway pressure) machine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist Resident #35 with grooming his beard per his preference and the facility failed to assist Resident #55 with showers as scheduled. This affected two residents, (#35 and #55) of three residents reviewed for grooming and hygiene. The facility census was 59.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to monitor Resident #43's blood sugar prior to meals. This affected one resident (#43) of three residents reviewed for blood sugar monitoring related to diabetes mellitus. The facility census was 59.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure weekly skin assessments were completed to prevent the development of a stage III pressure ulcer. This affected one resident (#3) of three residents reviewed for pressure ulcers. The facility census was 59.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to complete a smoking assessment and care plan for Resident #8 prior to allowing him to independently smoke with no supervision and allowing him to keep his cigarettes and lighter in his room unsupervised. This affected one resident (#8) of three residents reviewed for smoking. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to provide a bladder retraining program for Resident #267 per the Minimum Data Set (MDS) and care plan for. This affected one resident (#267) of three residents reviewed for incontinence. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were timely addressed by the physician. This affected one resident (#2) of five residents reviewed for unnecessary medications. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure blood pressure parameters for medications were measured and followed. This affected one resident (#52) of five residents reviewed for unnecessary medications. The facility census was 59.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure COVID-19 positive residents received appropriate orders, monitoring, and documentation of their COVID-19 status. This affected one resident (#43) of three residents reviewed for transmission-based precautions. The facility also failed to ensure resident mechanical ventilation machines were stored in a sanitary manner, affecting one resident (#22) of two residents reviewed for respiratory care. The total census was 59.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure call lights were kept plugged in and within reach. This affected three residents (#21, #43, and #117) of 27 residents surveyed for call light access. The facility census was 59.

Inspectors wroteBased on observation, interview, record review, and review of the facility Housekeeping policy the facility failed to ensure Resident #22's room was maintained in clean and sanitary condition. This affected one resident (#22) of 23 residents reviewed in the survey sample. The facility census was 59.

Inspectors wroteBased on observation and interview the facility failed to ensure the pest control services provided eliminated the ants in the kitchen. This had the potential to affect the 56 residents who received meals prepared by the kitchen. The facility identified Resident #18, #49, and #57 as receiving no food from the kitchen. The facility census was 59. Findings Include: Observation and interview on 03/27/23 at 9:48 A.M. at the end of the kitchen tour with Certified Dietary Manger (CDM) #352 revealed there were many ants observed directly outside the CDM's office in the kitchen. They hadn't been there ten minutes prior. CDM #352 stated maintenance had been told the kitchen was having an ant problem but didn't know what had been done beside the standard pest control visits. CDM #352 grabbed a can of Raid insect killer spray from right inside the office door and sprayed the group of small ants.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, safe and homelike environment. This affected all 49 residents (Residents #32, #38, #92, #4, #100, #76, #54, #23, #11, #56, #61, #13, #16, #30, #9, #93, #36, #44, #60, #95, #71, #65, #24, #111, #103, #99, #74, #86, #27, #59, #27, #48, #41, #94, #2, #66, #77, #63, #34, #6, #8, #31, #33, #40, #28, #104, #37, #80, and #79) that resided on the second floor. The facility census was 107.

Inspectors wroteBased on interview and record review, the facility failed to ensure night time snacks were provided consistently. This had the potential to affect all residents except four residents (Residents #87, #110, #15, and #20) who received nothing by mouth. The facility census was 107.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all but four residents (Residents #87, #110, #15, and #20) who received nothing by mouth. The facility census was 107.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments. This affected two residents (Residents #73 and #99) of 26 residents' MDS assessments reviewed. The facility census was 107.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the baseline plan of care to residents or resident representatives. This affected two residents (Resident #4 and #64) of two residents reviewed for baseline care plans. The facility census was 107.

Inspectors wroteBased on medical record review, staff interview and resident interview, the facility failed to ensure all residents received showers according to their preferences. This affected two (Resident #58 and Resident #66) of three residents reviewed for showers. The facility census was 107.

Inspectors wroteBased on observation, record review, interview and review of manufacture's guidelines, the facility failed to properly administer a physician ordered medication to meet the needs of Resident #91 and failed to ensure a physician ordered medication was readily available in a timely manner for Resident #106. This affected two (Residents #91 and #106) of eight residents reviewed for medication administration. The facility census was 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure as needed (PRN) medication orders for psychotropic drugs were limited to 14 days or that the facility physician justified in the medical record continued use of such medications. This affected one (Resident #32) of six residents (Residents #32, #46, #64, #90, #99 and #106) reviewed for unnecessary medications. The facility census was 107.