Otterbein Gahanna

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect 16 (#7, #8, #12, #13, #14, #16, #20, #22, #28, #31, #35, #40, #44, #46, #49, and #51) of 16 residents residing in houses with 300 and 500 numbered rooms. The facility census was 52.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to maintain a homelike environment by ensuring interventions were in place per the care plan to prevent repeated uninvited and unwanted visitors into resident rooms. This affected one (Resident #17) of three residents reviewed for resident rights. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, and review of the Resident Assessment Instrument manual, the facility failed to complete a significant change Minimum Data Set assessment in a timely manner following the identification of a significant change in condition. This affected one (Resident #53) of one residents reviewed for significant changes. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately complete a level one Pre-admission Screening and Resident Review (PASARR) documents for residents with serious mental illness diagnoses as required. This affected two (#5 and #36) of two residents reviewed for PASRRs. The facility census was 52.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of a facility procedure, the facility failed to ensure residents received adequate and routine hair care. This affected one (#17) of three residents reviewed for personal care. The facility census was 52.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure skin integrity interventions were implemented as care planned and ordered and failed to ensure medical appointments were scheduled and completed as required. This affected one (#22) of two residents reviewed for skin integrity and one (#40) of one residents reviewed for medical appointments. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure treatments for pressure ulcers were completed as ordered. This affected one (Residents #22) of three residents reviewed for skin integrity. The facility census was 52.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure residents received appropriate care and services related to maintain adequate foot care. This affected one (#20) of one residents reviewed for foot care services. The facility's census was 52.

Inspectors wroteBased on medical record review, review of dialysis documents, staff interview, and facility policy review, the facility failed to ensure required pre and post dialysis vital signs were completed as ordered. This affected one (Resident #1)of one residents reviewed for dialysis services. The facility census was 52.

Inspectors wroteBased on resident record review, review of pharmacy recommendations, and staff interviews, the facility failed to ensure pharmacy recommendations were reviewed and acted upon timely. This affected two (Resident #2 and Resident #8) of five residents reviewed for unnecessary medications. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medications were administered as ordered to prevent significant medication errors. This affected two (Resident #13 and Resident #1) of three residents reviewed for medication management. The facility census was 52.

Inspectors wroteBased on observation, staff interview, medical record review, review of a drug manufacturer instructions, and facility policy review, the facility failed to ensure insulin pens were appropriately stored in medication cart. This affected one (#12) of one residents reviewed for insulin storage. The facility census was 52.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to ensure laboratory (lab) services were timely in reporting lab results to meet resident needs. This affected one (#42) of three residents reviewed for bowel and bladder care needs. The census was 52.

Inspectors wroteBased on observation, medical record review, emergency medical services run report review, hospital documentation review, staff interview, resident representative interview, and review of meal menus and food recipes, the facility failed to ensure a thorough procedure was implemented to ensure staff members did not serve food items to residents with specific food allergies and intolerances. This affected two (#64 and #23) of three residents reviewed for food allergies. The facility census was 52.

Inspectors wroteBased on medical record review, resident and staff interview, review of the incident and accident log, and policy review, the facility failed to ensure weekly skin assessments were accurately documented in the medical record and failed to ensure the medical record was complete related to resident incident documentation. This affected one (Resident #1) of one residents reviewed for assessment accuracy. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a Centers for Disease Control and Prevention sign, the facility failed to ensure infection control measures were utilized for residents on enhanced barrier precautions. This affected one (#13) of eight residents reviewed for infection control. The facility census was 52.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to notify the physician and/or registered dietician when Resident #44 did not have physician ordered enteral nutrition available and failed to report Resident #48's weight loss. This affected two (Resident #44 and Resident #48) of three residents reviewed for change in condition. The facility census was 54.

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to provide a comprehensive and individualized pressure ulcer plan to aid in the prevention and/or treatment of pressure ulcers. This affected two (Resident #4 and #50) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a comprehensive, resident centered treatment plan was implemented to support identified needs related to enteral nutrition and failed to maintain appropriate parameters to accurately assess nutritional status. This affected two (Resident #44 and Resident #60) of three residents reviewed for nutrition. The facility census was 54.

Inspectors wroteBased on record review, hospital record review, interview, and policy review, the facility failed to ensure medications were necessary prior to administration and were administered per orders, non-pharmalogical interventions were attempted prior to administration of as needed pain medication and residents did not experience adverse effects from prescribed medications that resulted in hospitalization. This affected one (Resident #60) of three residents reviewed for narcotic medication use. The facility census was 54.

Inspectors wroteBased on record review and interviews, the facility failed to notify the physician of laboratory results for Resident #60. This affected one (Resident #60) of three residents reviewed for laboratory results. The facility census was 54.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean kitchen environment. This had the potential to affect all residents except Resident #1 who does not receive food from the kitchen. The facility census was 55.

Inspectors wroteBased on observation, staff interview, medical record review, manufacture's guidelines, and policy review the facility failed to ensure insulin pens were primed before administering insulin to the residents. This affected one resident (#47) of one resident reviewing for insulin pen priming. The facility identified two residents (#47 and #55) in House #1 who received insulin. The facility census was 55.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review the facility failed to ensure insulin pens were primed before administering insulin to the residents. This affected one resident (#23) of one resident reviewed for insulin pen priming. The facility identified five residents (#14, #15, #18, #19 and #23) in House #2 who received insulin. The facility census was 54.

Inspectors wroteBased on medical record review, observations, staff interview and policy review the facility failed to ensure glucometers were sanitized between residents. This affected three (#14, #15, #23) of three residents reviewed for medication administration. The facility identified this had the potential to affect five residents (#14, #15, #18, #19 and #23) who received accuchecks in House #2. The facility census was 54.

Inspectors wroteBased on observation, interview, and review of facility policy the facility failed to ensure foods were stored in a sanitary manner and failed to ensure foods were labeled, dated, stored appropriately, and not kept past the expiration dates. This had the potential to affect 50 of 50 residents in the facility.

Inspectors wroteBased on observation, record review, staff interview and policy review the facility failed to ensure enhanced barrier precautions (EBP) were in place for five residents (Resident #32, #52, #45, #110, #45 and #1) of seven residents reviewed for enhanced barrier precautions. The facility failed to ensure an isolation room contained appropriate bins for staff to place soiled laundry and to dispose of soiled personal protective equipment (PPE) for one resident,( Resident #10) of one reviewed for transmission-based precautions. The facility failed to provide evidence the infection control policies and procedures are reviewed annually. This had the potential to affect all 50 residents in the facility as each home of the facility had residents who were not in enhanced barrier precautions who had physician orders to have enhanced barrier precautions implemented in their care. [...]

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure a full set of utensils and napkins was provided for all residents in houses 400 (#8, #11, #14, #18, #20, #21, #32, #34, #38) and 404 (#6, #9, #19, #22, #24, #28, #33, #35, #40, #45), additionally the facility failed to ensure a dignified dining experience for Resident #19. This affected 19 residents (#6, #8, #9, #11, #14, #18, #19, #20, #21, #22, #24, #28, #32, #33, #34, #35, #38, #40, #45) observed for dining. The facility census was 50.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure Resident #52 received assistance at meals as needed, and failed to ensure routine shaving, nail care, and/or showers were provided for Resident #25, #32, #35, and #45. This affected five residents (#25, #32, #35, #45, and #52) of six residents reviewed for activities of daily living. The facility census was 50.

Inspectors wroteBased on medical record review, resident and staff interview, and observation, the facility failed to assess, implement, and deliver an individualized activity program for six residents (Resident #19. #22, #32, #34, #35, and #51) of six residents reviewed for activities. The facility census was 50.

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to identify, assess and monitor skin conditions for two residents (#19 and #31) and failed to ensure one resident's (#48) wound treatments were completed as physician ordered. This affected three of three residents reviewed for skin conditions. Additionally, the facility failed to ensure one resident's (#11) Thromboembolism-Deterrent (TED) hose were applied as physician ordered. This affected one of one residents revived for edema. The facility census was 50. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure fall interventions were in place for Resident #8, #19, #25, #28, and #52 and failed to ensure sufficient fall documentation and neurological checks were completed for Resident #19 and #110. Additionally, the facility failed to ensure Resident #48 was not left unsupervised. This affected seven residents (#8, #19, #25, #28, #48, #52, and #110) of nine residents reviewed for accidents. The facility census was 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #19, #22, and #32 had reasonable access to fluids, failed to offer Resident #34 food purchased and brought in by family, and failed to offer Resident #25 ice cream following dinner as care planned. This affected four residents (#19, #22, #32, and #34) of ten residents reviewed for nutrition and hydration. The facility census was 50.

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to change and date oxygen tubing and supplies as ordered and failed to store respiratory equipment in a safe and sanitary manner. This affected four residents (#11, #21, #31, #38) of four residents reviewed for respiratory care. The census was 50. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 04/07/23 with the latest readmission of 01/12/24, diagnoses included hypertensive heart disease with heart failure, asthma, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and obstructive sleep apnea. Review of the plan of care dated 01/12/24 revealed the resident had an alteration in respiratory status related to COPD, asthma and chronic respiratory failure. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of facility menus the facility failed to ensure the menu was followed for Resident #19 and the facility failed to ensure a planned menu was in place for residents on a puree and mechanically altered diet. This had the potential to affect all 11 residents on a puree and mechanically altered diet (#8, #9, #17, #19, #24, #29, #34, #40, #50, #52, and #100). The facility census was 50.

Inspectors wroteBased on record review and staff and family interviews, the facility failed to ensure one resident (#25) was provided bathing per her preference. This affected one ( Resident #25) of six residents reviewed for activities of daily living (ADL). The facility census was 50. Findings Include: Review of the medical record for Resident #25 revealed an initial admission date of 01/17/24 with the diagnoses including but not limited to congestive heart failure, hyperlipidemia, hypothyroidism, chronic kidney disease, atrial fibrillation, hypertension, gastro-esophageal reflux disease, macular degeneration and protein calorie malnutrition. Review of the plan of care dated 03/22/24 revealed the resident had a self-care deficit and/or physical mobility performance deficit related to activity intolerance, fatigue, impaired balance and weakness. [...]

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure one resident's (#31) physician was notified of vital signs outside of the physician ordered parameters. This affected one ( Resident #31) of 24 sampled residents reviewed. The facility census was 50. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 02/26/22 with the latest readmission of 09/05/24 with the diagnoses including but not limited to cellulitis of left upper limb, cardiomyopathy, hypertension, ulcerative colitis, cerebrovascular accident with left sided hemiplegia, anemia, severe protein calorie malnutrition, hyperlipidemia, congestive heart failure, presence of cardiac pacemaker, anxiety disorder and major depressive disorder. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one resident's (#31) required resident information for emergency transfer was documented in the resident's medical record and provided for the receiving facility. This affected one (Resident #31) of three residents reviewed for hospitalization. The facility census was 50. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 02/26/22 with the latest readmission of 09/05/24 with the diagnoses including but not limited to cellulitis of left upper limb, cardiomyopathy, hypertension, ulcerative colitis, cerebrovascular accident with left sided hemiplegia, anemia, severe protein calorie malnutrition, hyperlipidemia, congestive heart failure, presence of cardiac pacemaker, anxiety disorder and major depressive disorder. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #7) three residents reviewed for PASARR documents. The census was 50.

Inspectors wroteBased on record review and staff interviews the Preadmission Screening And Resident Review (PASARR) did not reflect all mental health diagnoses for two residents (Resident #7 and #28) out of three residents reviewed for PASARR accuracy. The facility census was 50.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #7) of three residents reviewed for PASRR documents. The census was 50. Findings Include: Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. On 06/14/23 additional diagnoses of psychotic disorder with delusions and other hallucinations were added. Review of the PASARR provided on 09/10/24 revealed it was completed on 03/20/23 by the facility. The PASARR indicated there was no mental diagnoses. [...]

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to develop a comprehensive plan of care to address resident needs and conditions as required. This affected three (#31, #32, and #52) of 24 sampled residents reviewed for careplans. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 02/26/22 with the latest readmission of 09/05/24 with the diagnoses including but not limited to cellulitis of left upper limb, cardiomyopathy, hypertension, ulcerative colitis, cerebrovascular accident with left sided hemiplegia, anemia, severe protein calorie malnutrition, hyperlipidemia, congestive heart failure (CHF), presence of cardiac pacemaker, anxiety disorder and major depressive disorder. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure quarterly care conferences were conducted and the required interdisciplinary team (IDT) members were present at care conferences. This affected two residents (#25 and #34) of 24 sampled residents. The facility census was 50. Findings Include: 1. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. This affected one resident (#54) of one resident revived for discharge. The facility census was 50. Findings Included: Review of the closed medical record for Resident #54 revealed an initial admission date of [DATE] with the diagnoses including compression fracture of T11-T12, metabolic encephalopathy, hypertension, hyperlipidemia, hypothyroidism, anxiety disorder, major depressive disorder and pressure ulcer Stage II buttocks. The resident was discharged to an assisted living facility on [DATE]. Review of the resident's admission screen and baseline care plan dated [DATE] revealed the resident was alert and oriented to person only on admission. The assessment indicated the resident was confused. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the timely assessment and treatment of a urinary tract infection (UTI) for one resident (#22). This affected one of one reviewed for UTI. Additionally, the facility failed to ensure one resident (#32) had physicians orders for the use of an indwelling urinary catheter. This affected one (#32) of two residents reviewed for catheter use. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #32 revealed an initial admission date of 01/21/23 with the latest readmission of 07/06/24 diagnoses included sepsis, urinary tract infection, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, obstructive and reflux uropathy, dementia with behavioral disturbances, intellectual disabilities and hypertension. [...]

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure Resident #52's tube feeding formula was appropriately labeled and dated after opening. This affected one resident of one resident reviewed for tube feeding. The facility census was 50.

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmacy recommendations were addressed by the physician and followed through by facility staff for one, (Resident #35) and failed to have evidence of the pharmacist's recommendations for one, (Resident #22). This affected two residents (#22 and #35) of five residents reviewed for un-necessary medications. The facility census was 50.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were appropriately monitored as ordered when administered medications. This affected one (Resident #38) of four residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 07/19/23 with the latest readmission of 12/16/23 with diagnoses including but not limited to chronic respiratory therapy, congestive heart failure (CHF), hypertension, atrial fibrillation and chronic pain. Review of the plan of care dated 07/31/23 revealed the resident had an altered cardiovascular status related to arrhythmia, CHF, hypertension and atrial fibrillation. Interventions included administer medications as ordered. [...]

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to secure and store medications appropriately. This affected one (#38) of two residents observed during medication administration. The facility census was 50. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 07/19/23 with the latest readmission of 12/16/23, diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory therapy, congestive heart failure, hypertension, atrial fibrillation and chronic pain. Review of the plan of care dated 09/14/23 revealed the resident had a physician's order for unsupervised, self-administration of the nebulizer treatments. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure puree food items were cooked and brought back up to temperature following the completion of puree method. This affected two of two residents residing in the 400 house. The census was 50.

Inspectors wroteBased on observations, interview, medical record review, and review of diet guides the facility failed to ensure Resident #40 was served food appropriate for a soft and bite sized texture diet and Resident #52 was served food appropriate for a pureed texture diet. This affected two residents (#40 and #52) of five residents on a puree diet and three residents on a soft and bite sized diet. The facility census was 50.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure one resident (#32) was provided the physician ordered adaptive equipment for meals. This affected one of nine residents reviewed for nutrition. The facility census was 50. Findings Include: Review of the medical record for Resident #32 revealed an initial admission date of 01/21/23 with the latest readmission of 07/06/24, diagnoses included osteoarthritis, vitamin D deficiency, chronic pain syndrome, major depressive disorder, dementia with behavioral disturbances, intellectual disabilities and hypertension. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record. This affected two (#11 and #31) of 24 sampled residents. The facility census was 50. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 04/07/23 with the latest readmission of 01/12/24, diagnoses included hypertensive heart disease with heart failure, asthma, pain, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, severe morbid obesity, vitamin D deficiency, pancytopenia, obstructive sleep apnea and gastro-esophageal reflux disease. Review of the plan of care dated 01/12/24 revealed the resident had an alteration in respiratory status related to COPD, asthma and chronic respiratory failure. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure Resident #45's room was maintained in a clean and homelike manner and failed to ensure appropriate water temperature and water drainage for Resident #33. The facility census was 50.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident representatives were informed of all medical appointments. This affected one (Resident #32) of three residents reviewed for medical appointments. The census was 56.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure food was dated, not kept past its use by date, thermometers were in place to monitor refrigerator and freezer temperatures, eggs were pasteurized, and that food temperatures were obtained prior to serving meals to residents. This was observed in all five kitchens. This had the potential to affect 56 of 56 residents who consumed food from the kitchen.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to notify the physician and resident representatives of a significant weight change for three residents (Residents #1, #12, and #45), a new skin condition for one resident (Resident #12), and one cognitively impaired resident's (Resident #53) continued refusals for intravenous hydration and hospitalization with a critically high potassium level. The deficient practice affected four residents (Residents #1, #12, #45, and #53) of four residents reviewed for notification of change. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. [...]

Inspectors wroteBased on interview and record review the facility failed to develop comprehensive care plans that included activities, bladder and bowel, nutrition, hydration, respiratory care, position, mobility, and behaviors. This affected six residents (#3, #12, #33, #39, #45, and #53) of 27 records reviewed. The facility census was 56.

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure personal hygiene was completed for six residents (#7,#13, #24, #31, #33, #41), who were dependent on staff. Additionally the facility failed to ensure two residents (#8, #21) received scheduled showers. This affected eight of ten residents reviewed for activities of daily living (ADLs). The facility census was 56. Findings Included: 1. Review of the medical record for Resident #7 revealed an initial admission date of 05/03/21 with the latest readmission of 11/30/22 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, chronic peripheral venous insufficiency, diabetes mellitus, hypertension, hyperlipidemia, right knee contracture, left knee contracture, gout, gastro-esophageal reflux disease and pain. [...]

Inspectors wroteBased on observation, interview, record review, and review of the activities calendar, the facility failed to provide activities in the evening and on the weekends, which had the potential to affect cognitively impaired residents, additionally, the facility failed to develop an individualized activity plan for Resident's #7, #39, and #210, and provide independent activities for Resident #12 and #210. This affected four residents (#7, #12, #39, and #210) of four reviewed for activities and had the potential to affect all cognitively impaired residents in the facility. The facility census was 56.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure one resident (#24) received appropriate and timely treatment for a urinary tract infection (UTI). This affected one of four residents reviewed for catheter/UTI. Also, the facility failed to ensure indwelling urinary catheter collection bag was covered with a privacy bag for four residents (#1, #24,#52, #53) reviewed for indwelling urinary catheter and one resident (#210) reviewed for bowel and bladder. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #24 revealed an initial admission date of 07/05/22 with the diagnoses including senile degeneration of brain, dementia, severe protein calorie malnutrition, dysphagia, hyperlipidemia, osteoarthritis, hypertension, bipolar disorder, diverticulosis of intestine, retention of urine and disorders of bladder. [...]

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to ensure nutritional supplements were administered as ordered to three residents (Residents #1, #45, and #210), failed to timely address significant weight changes for two residents (Residents #1 and #12), and failed to ensure fluids were kept within reach of two residents (Residents #12 and #53). This deficient practice affected five residents (Residents #1, #12, #45, #53, and #210) out of 12 residents reviewed for nutrition and hydration. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date on 03/30/23 and a readmission date on 04/26/23. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure staff were competent to serve meals according to the menu and diet order, to obtain temperatures prior to serving food, and use appropriate serving sizes. This affected all 44 residents residing in buildings #400, #401, #402, and #403. The facility census was 56.

Inspectors wroteBased on observation, interview, and review of the menu, the facility failed to ensure the menu, recipes, and portion sizes were followed in all buildings. This affected all 44 residents residing in buildings #400, #401, #402, and #403. The facility census was 56.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure four residents (Residents #3, #25, #41, and #44) were served the appropriate textured diet as ordered. The deficient practice affected four residents (Residents #3, #25, #41, and #44) of 12 residents reviewed for food and nutrition. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side, cognitive communication deficit, and major depressive episode-recurrent. There were no other mental health diagnoses listed. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the environment was maintained in a clean, odor free, and homelike manner for Resident #1, #2, #10, #17, #12, and #39. This affected six residents (#1, #2, #10, #12, #17, and #39) of nine residents reviewed for environment. The facility census was 56.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #19's advanced directives were in the electronic medical record and failed to ensure Resident #12 and #29's advanced directives matched the signed documents. This affected three residents (#12, #19, and #29) of seven reviewed for advanced directives. The facility census was 56.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to revise comprehensive care plans for two residents (Resident #3 and #13) to address changes in status, including the need for supervision with all meals and discontinuation of a wound vac. The deficient practice affected two residents (Resident #3 and #12) of 23 residents reviewed in the final sample for care plans. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and document on new skin concerns for Resident #10 and Resident #12, and failed to ensure hospice documentation in facility for Resident #210. The facility census was 56.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program to provide timely and necessary treatment and services to residents with pressure ulcers to prevent, promote healing and decrease the risk of decline of pressure ulcers. This affected three residents (#13, #52, and #159) of four residents reviewed for pressure ulcers. The facility census was 56. Findings Include : 1. Review of the medical record for Resident #159 revealed an admission date on 05/01/23. Medical diagnoses included nondisplaced fracture of right femur, displaced fracture of olecranon process of right ulna (forearm), congestive heart failure (CHF), hypotension (low blood pressure), anemia (low iron level), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to obtain a physician's order for the use of an orthopedic back brace for one resident (Resident #3). This affected one resident (Resident #3) out of five residents reviewed for positioning and range of motion. The facility census was 56. Findings Include: Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure oxygen nasal cannula tubing was changed weekly as physician ordered for two residents (#3, #40). Also, the facility failed to ensure respiratory equipment was stored properly to prevent infection for Resident #40. This affected two of two residents reviewed for oxygen therapy. The facility identified seven residents receiving respiratory treatments. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 08/12/20 with the latest readmission of 05/02/23 with the diagnoses including cerebrovascular accident with right sided hemiplegia, diabetes mellitus, atrial fibrillation, hypertension, gastro-esophageal reflux disease, hyperlipidemia, cardiomyopathy, anemia, chronic kidney disease and dysphagia. [...]

Inspectors wroteBased on interview and record review the physician failed to date when he addressed pharmacy recommendations and failed to provide reasoning for declining a gradual dose reduction (GDR) recommendation from the pharmacist for Resident #29. This affected one resident (#29) of five residents reviewed for unnecessary medications. The facility census was 56.

Inspectors wroteBased on interview and record review the facility failed to ensure medication parameters were monitored as ordered for Resident #12. This affected one resident (#12) of five reviewed for unnecessary medications. The facility census was 56.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure antipsychotics were used with a proper diagnosis for two resident (Residents #3 and #46). The deficient practice affected two (Residents #3 and #46) of five residents reviewed for unnecessary medications. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date on 03/30/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, dysphagia oropharyngeal phase, chronic obstructive pulmonary disease with acute exacerbation, and multiple fractures of ribs on right side, cognitive communication deficit, and major depressive episode-recurrent. There were no other mental health diagnoses listed. [...]

Inspectors wroteBased observation, interview, and medical record review, the facility failed to ensure Resident #19's prescribed medications were stored securely. This affected two residents (#10 and #19) of two residents reviewed for medication storage. The facility census was 56.

Inspectors wroteBased on record review, observation, and interview the facility failed to serve pureed foods in an appropriate and palatable manner. This affected one resident (#25) of two receiving a pureed diet. The facility census was 56.

Inspectors wroteBased on observation, interview, review of the facility menu and facility policy review, the facility failed to ensure one resident (#41) received the requested food as scheduled on the facility menu. This affected one of 12 residents residing in house 402. The facility census was 56.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure Resident #31 and #210 received timely meal assistance and that Resident #15 was served lunch without intervention. This affected three out of three people observed for timely meals. The facility census was 56.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to accurately document the administration of nutritional supplements for two residents (Resident #1 and #45). The deficient practice affected two residents (Resident #1 and #45) of 12 residents reviewed for food and nutrition. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #45 revealed an admission date of 12/12/22 with diagnoses including Alzheimer's disease, hyperlipidemia, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition. She weighed 115 pounds and had no significant weight changes. Review of the physician order dated 03/01/23 to 05/17/23 revealed an order for health shake three times a day. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices to prevent the potential spread of infection in the area of wound care, incontinence care, glucometer (machine used to check blood sugar), and proper storage of catheter bags. The deficient practices had the potential to affect one (Resident #53) of four residents reviewed for catheters, one (Resident #13) of four residents reviewed for pressure ulcers, one (Resident #13) of one residents reviewed for incontinence care, and one (Resident #17) of one residents reviewed for glucometer testing. The facility census was 56. Findings Include: 1. [...]