Westerville Post Acute

Inspectors wroteBased on observations, medical record review, staff and resident interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of one resident (#640) out of five residents observed for call light placement. The facility census was 89.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure dietary preferences were honored. This affected two residents (#605 and #630) of five residents reviewed for food preferences. The facility census was 89.

Inspectors wroteBased on observations, interviews, record review, the facility failed to follow infection control procedures during incontinence care. This affected one residents (#630) of the five residents reviewed for incontinence care. The facility census was 89.

Inspectors wroteBased on medical record review, staff interviews, pharmacist interview, and review of facility policy, the facility failed to have an adequate post discharge plan for medication administration when the facility did not ensure an adequate supply of medications were available for a resident at discharge. This affected one former resident (#95) out of three residents reviewed for discharge planning. The facility census was 91 residents. Findings Include:Review of a closed medical record revealed that former Resident #95 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, hypertension, malignant neoplasm of kidney, and atrial fibrillation. Review of Resident #95's Minimum Data Set (MDS) 3.0 assessment on 12/12/25 revealed that Brief Interview with Mental Status (BIMS) score of 15, indicative of intact cognitive status. [...]

Inspectors wroteBased on review of resident medical records, resident interviews, staff interviews and review of facility policy, the facility failed to offer activities of interest to residents. This affected one resident (#95) out of four residents reviewed for activities. The facility census was 91 residents.

Inspectors wroteBased on observation, record review, interviews, and review of facility policy, the facility failed to ensure Resident #25 was free from a significant medication error when the physician was not notified of a high blood glucose per sliding scale order. This affected one resident (#25) of two residents reviewed for insulin management. The facility census was 91. Findings Include: Review of Resident #25's medical record revealed an admission date of 04/25/26 with diagnoses that included but were not limited to diabetes type one (DM), hypertension and chronic obstructive pulmonary disease. Review of Resident #25's functional abilities assessment dated [DATE] revealed he required assistance from staff with toileting, dressing and mobility. Review of Resident #25's physicians orders dated 04/25/26 revealed the following orders for insulin: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that opened bulk medications were properly labeled with an open date or discard date to prevent the risk of use of contaminated or expired medications. This had the potential to affect all 32 residents in the 400 hall receiving medications. The facility census was 91. Findings Include: Observation on 05/05/26 at 7:45 A.M. of medication storage for the 400 hall nurses cart revealed the following opened and undated bulk medications: Milk of Magnesia 473 milliliter (ml) bottle that was half empty; Tylenol 325 milligram (mg) 100 count bottle that was half empty; Tylenol 500 mg 100 count bottle that was half empty; Active Liquid Protein 887 ml bottle that was half empty; Geri-Tussin 473 ml bottle that was half empty; and Alkums antacid tablets 150 count bottle that was half empty. Interview on 05/05/26 at 7:45 A.M. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure dressing changes were completed as ordered by the physician. This affected one (Resident #16) out of three residents reviewed for wound care. The facility census was 84.

Inspectors wrote2. Review of Resident #25's medical record revealed an admission date of 10/04/21 with diagnoses including epileptic seizures related to external causes, disease of esophagus, major depressive disorder, anxiety disorder, encephalopathy, dysphagia, psychotic disorder with delusions, personal history of traumatic brain injury, and other sexual dysfunction not due to a substance or known condition. Review of Resident #25's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. He had verbal behaviors directed towards others and rejection of care daily. Review of Resident #25's plan of care dated 04/15/24 revealed he required the use of psychotropic medications with potential for adverse reactions related to diagnoses. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure accurate coordination with the Pre-admission Screening and Resident Review (PASARR) process by submitting an incorrect list of mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for PASARR. The facility census was 83.

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR). The facility census was 83.

Inspectors wroteBased on interview and record review the facility failed to hold a timely admission care conference for one resident. This affected one resident (#188) of three residents sampled for care planning. The facility census was 83.

Inspectors wroteBased on observation, resident interview, staff interviews, personnel file reviews, record review and policy review, the facility failed to ensure activities were offered to meet the individualized needs of a resident. This affected one resident (#48) of one resident reviewed for activities. The facility census was 83. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 10/07/24. Pertinent diagnoses included: chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, chronic diastolic (congestive) heart failure, schizoaffective disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review revealed the facility failed to ensure a hand protector was in place for Resident #35 as ordered. This affected one resident (#35) of three residents reviewed for positioning and mobility. The facility census was 83.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure a complete investigation was completed to determine root cause analysis when a resident sustained a fall and failed to ensure fall safety interventions were in place as per residents care plan. This affected three residents (#238, #3, and #79) of the six residents reviewed for accidents and falls. Facility census was 83.

Inspectors wroteBased on interview, observation, and record review the facility failed to timely or accurately implement nutrition recommendations for Resident #13, #35, and #81. This affected three residents (#18, #35, #81) of seven residents reviewed for nutrition. The facility census was 83.

Inspectors wroteBased on interview, policy review, and record review the facility failed to identify and make staff aware of trauma triggers for a resident with post-traumatic stress disorder and failed to provide consistent psychosocial intervention. This affected one resident (#45) of one sampled for mood and behavior. The facility census was 83.

Inspectors wroteBased on observation, interview, and facility policy review, this facility failed to ensure controlled substances were logged or signed out in the control substance log when that medication was administered. This affected one resident (Resident #44) of the four residents reviewed during medication administration observation. The facility census was 83.

Inspectors wrote3. Review of Resident #3's medical record revealed that she was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 with foot ulcer and chronic kidney disease, malnutrition, paraplegia, discitis, borderline personality disorder and chronic pulmonary obstruction. She was alert and oriented. Review of Resident #3's clinical physician orders dated 05/30/25 revealed orders for Aspirin Oral Tablet Chewable 81 MG; give 1 tablet by mouth one time a day for hypertension, Insulin Glargine Subcutaneous Solution 100 UNIT/ML; inject 12 unit subcutaneously at bedtime for type 2 diabetes, Hydrochlorothiazide Tablet 25 MG; give 1 tablet by mouth one time a day for hypertension and edema, Ramelteon Oral Tablet 8 MG; give 1 tablet by mouth at bedtime for Insomnia and Gabapentin Capsule 400 MG; give 1 capsule by mouth three times a day for nerve pain. [...]

Inspectors wroteBased on resident interviews, staff interviews, record review, policy review and safety data sheet review, the facility failed to ensure Resident #38 was free from significant medication errors. This affected one resident (#38) of one resident reviewed for medication errors. The facility census was 83. Findings Include: Record review revealed Resident #38 was admitted to the facility on [DATE]. Pertinent diagnoses included: type 2 diabetes mellitus with hyperglycemia, long term (current) use of insulin, acquired absence of right foot, acquired absence of left leg below knee, severe obesity and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #38 revealed he was cognitively intact. The functional assessment rated Resident #38 as independent on eating, hygiene, dressing and transfers, with supervision needed for showers/bathing. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, this facility failed to ensure medication stored in the medication room and medication carts were properly labeled with an open date. This affected two residents (#33 and #243) of the four residents reviewed during medication administration. The facility census was 83.

Inspectors wroteBased on medical record review and staff interview the facility failed to complete physician ordered lab tests. This affected one resident (#79) of three residents reviewed for lab tests.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to ensure resident medical records contained information related to a resident's hospital admission. This affected one resident, (#238) of the six residents reviewed for accidents and falls. Facility census was 83.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure enhanced barrier precautions were maintained during skin care. This affected one resident (#35) out of 16 residents on enhanced barrier precautions. The facility census was 83.

Inspectors wroteBased on medical record review, staff interviews, hospital record review, review of emergency medical services (EMS) run reports, review of prescribing information for NPH 70/30 Insulin, and facility policy review, the facility failed to ensure Resident #104's blood sugar levels were adequately monitored to prevent incidents of hypoglycemia. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure their medication error did not exceed five percent. The facility had two medication errors out of 28 opportunities resulting in a medication error rate of 7.14 percent. This affected two (Resident #30 and Resident #36) of five residents reviewed for medication administration. The census was 102.

Inspectors wroteBased on closed medical record review, review of a facility self-reported incident (SRI) and investigation, review of a police report, review of emergency medical service (EMS) report, review of the hospital reports, review of the facility's Abuse/Neglect policy and procedure, and interviews with the police, family, and staff, the facility failed to ensure Resident #109, who was admitted to the facility for abdominal surgical wound care was free from a situation of neglect when facility staff failed to provide appropriate and timely wound treatment, care, and services. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and medical emergency on 02/03/04 when Resident #109 and her family identified delayed and improper wound care resulting in the family's call to local police for a welfare check. [...]

Inspectors wroteBased on medical record review, review of a police report, interview with the local Fire Deputy Chief, residents and staff, review of the resident council minutes, review of emergency call records, and policy review, the facility failed to have sufficient staffing to meet the residents needs. This affected four residents (#28, #35, #58, and #109) and had the potential to affect all 104 residents currently residing in the facility.

Inspectors wroteBased on medical record review, review of the police report, review of the Emergency Medical Services (EMS) report, review of the hospital records, review of the facility's self-reported incident (SRI), staff interview, and facility policy review, the facility failed to timely report an allegation of resident neglect to the State Survey Agency, the Ohio Department of Health. This affected one (Residents #109) of three residents reviewed for abuse. The facility census was 104.

Inspectors wroteBased on record review, resident and staff interview, and policy review, the facility failed to timely treat a resident's pressure ulcers when they were first identified. This affected one (Resident #111) of three residents reviewed for wounds. The facility census was 104.

Inspectors wroteBased on closed medical record review, review of a Self-Reported Incident, review of the witness statements and police report, and resident and staff interviews, the facility failed to ensure Resident #90 was treated with dignity and respect. This affected one resident (#90) of three residents reviewed for dignity and respect. The facility census was 89.

Inspectors wroteBased on medical record review, review of the resident council minutes, and resident and staff interviews, the facility failed to ensure the residents were bathed according to their bathing preference. This affected two residents (#69 and #70) of three residents reviewed for bathing preferences. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely report a resident fall, timely assess Resident #61 status post fall to prevent further falls/accidents and failed to ensure the fall was documented in the resident's medical record. This affected one resident (#61) of three residents reviewed for falls. The facility census was 89.

Inspectors wroteBased on record review, review of the medication administration policy and procedure, and resident and staff interview, the facility failed to ensure controlled drug records and medication administration records were consistent and accurate to reflect the actual administration and accounting for controlled medications for Resident #69. This affected one resident (#69) of three residents reviewed for medications. The facility census was 89.

Inspectors wroteBased on observation, record review, review of hospital records, and interview, the facility failed to timely identify and assess symptoms of a urinary tract infection (UTI), accurately collect a sample of urine for testing, and notify the physician of contaminated urine specimens for Resident #24. Additionally, the facility failed to remove Resident #52's indwelling urinary catheter following the collection of a 24-hour urine. Actual harm occurred beginning on 07/04/23 when the facility failed to identify symptoms of UTI, treat the UTI with the appropriate antibiotics, and notify the physician of multiple contaminated urine samples causing Resident #24 to sustain a significant decline in condition. On 08/04/23 the resident was transferred to an acute care hospital for confusion and suicide attempt and was found to have a UTI. [...]

Inspectors wrote12. Review of the medical record for the Resident #79 revealed an initial admission date of 01/24/23 with several trips out to the hospital. Diagnoses included encephalopathy, fracture of the upper end right humerus, fracture of the third metacarpal left hand, fracture of the fifth metacarpal left hand, muscle weakness, liver cirrhosis and seizures. Review of fall admission assessment dated [DATE] revealed residents cognitive status had changed in the previous seven days and also revealed resident was confined to a chair with no previous falls. Review of the MDS assessment dated [DATE] revealed Resident #79 was cognitively intact and required assistance from staff for mobility. Review of Occupational Therapy (OT) notes dated 07/25/23 to 08/02/23 revealed resident used the wheeled walker and wheelchair for support when ambulating. [...]

Inspectors wroteBased on observation, staff interview and record review facility failed to ensure pureed foods were made to the correct texture and with following the recipe. This affected five Resident (#6, #25, #70, #74, and #88) with orders for pureed food. Facility census was 92.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one resident's indwelling urinary catheter collection bag was contained in a privacy bag. This affected one (Resident #52) of one reviewed for indwelling urinary catheter. The facility census was 92. Findings Include: Review of the medical record for Resident #52 revealed an initial admission date of 07/08/23 with the most recent readmission of 07/24/23 with diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one resident (#28) had a physician's order and was assessed for self-administration of medication. This affected one (Resident #28) of three residents observed for medication administration. The facility census was 92. Findings Include: Review of the medical record for Resident #28 revealed an initial admission date of 03/04/23 with the latest readmission of 07/14/23 with diagnoses including diabetes mellitus, cardiomyopathy, congestive heart failure, hyperlipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, hypertension, end stage renal disease, dependence on hemodialysis and gout. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairment. [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure one resident (#1) was bathed per their preference and one resident (#79) was dressed per their preference. This affected two ( Resident #1 and #79) of five residents reviewed for choices. The facility census was 92. Findings Include: 1. Review of the medial record for Resident #1 revealed an initial admission date of 04/27/23 with diagnoses including pneumonia, metabolic encephalopathy, dysarthria, dementia, depression, cerebral infarction, osteoarthritis, dysphagia, generalized muscle weakness and repeated falls. Review of the plan of care dated 07/13/23 revealed the resident had a self-care performance deficit related to CVA and dementia. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure two resident's (#5 and #52) room was free of a persistent odor of urine. This affected two (Resident #5 and #52) of seven residents reviewed for environmental concerns. The facility census was 92. Findings Included: 1. On 10/02/23 at 11:12 A.M., observation of Resident #52 revealed the resident had an indwelling urinary catheter. The resident's room had a strong odor of urine. Interview with Resident #52 revealed she could smell the odor of urine in her room and the smell bothered her. Resident #52 revealed she requested the indwelling urinary catheter collection bag be changed but to date had not been changed. On 10/02/23 at 3:35 P.M., observation of Resident #52's room revealed the room continued to have a strong odor of urine. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to report a suspected crime to local law enforcement. This affected one (Residents #16) of five resident incidents reviewed. The census was 92. Findings Include: Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to report alleged incidents in a timely manner. This affected two (Residents #16 and Resident #45) of five resident incidents reviewed. The census was 92. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to investigate an allegation of misappropriation. This affected one (Residents #16) of five resident incidents reviewed. The census was 92. Findings Include: Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to perform an accurate discharge assessment. This affected one (Resident #92) of three resident discharges reviewed. The census was 92. Findings Include: Resident #92 was admitted to the facility on [DATE]. His diagnoses were diverticulitis, type II diabetes, other chronic pain, hyperlipidemia, hypertension, arthrogryposis multiplex congenital, cognitive communication deficit, muscle weakness, depression, and vitamin D deficiency. Review of his minimum data set (MDS) assessment, dated 06/29/23, revealed he was cognitively intact. Review of Resident #92 MDS assessment section A, dated 08/03/23, revealed the facility documented he was discharged to a hospital. Review of Resident #92 progress notes, dated 08/04/23, revealed Resident #92 left the faciity on a leave of absence. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to revise comprehensive care plans for two residents (Residents #45 and #83). This affected two residents (Residents #45 and #83) out of 24 reviewed for comprehensive care plans. The facility census was 92.

Inspectors wroteBased on observation, record reviews, interviews, and policy review, the facility failed to ensure three residents (#1, #5 and #61) who were dependent on staff for bathing received scheduled showers and according to preference. This affected three (Resident #1,#5, and #61) of three residents reviewed for activities of daily living (ADLs). The facility census was 92. Findings Included: 1. Review of the medical record for Resident #61 revealed an admission date of 06/01/21 with diagnoses including unilateral primary osteoarthritis of the left knee, generalized muscle weakness, reduced mobility, cerebral infarction, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had intact cognition. Resident #61 required extensive one person assistance for personal hygiene. [...]

Inspectors wroteBased on observations, resident and staff interviews and record review, facility failed to ensure meaningful activities were offered and provided. This affected one Resident (#146) of three reviewed for activities. Facility census was 92.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to comprehensively assess one resident's (#78) Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer on admission, readmission and weekly there after. This affected one (Resident #78) of two residents reviewed for pressure ulcers. The facility census was 92. Findings Included: [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to administer a nutritional supplement to one resident (Resident #83) as ordered. This affected one resident (Resident #83) of six residents reviewed for nutrition. The facility census was 92. Findings Include: Review of the medical record for Resident #83 revealed an admission date on 08/29/23. Medical diagnoses included hypertensive heart disease with heart failure, dehydration, congestive heart failure (CHF), muscle weakness, and history of falling. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #83 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure residents had physician's orders in place for dialysis and monitoring of dialysis sites. This affected two ( Resident #28 and #52) of two residents reviewed for dialysis. The census was 92. Findings Included: 1. Review of the medical record for Resident #52 revealed an initial admission date of 07/08/23 with the most recent readmission of 07/24/23 with diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to administer as needed pain medication within parameters as ordered by the physician and failed to attempt non-pharmacological interventions prior to administering as needed pain medication for one resident (Resident #4). This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 92. Findings Include: Review of the medical record for Resident #4 revealed an admission date on 08/31/23. Medical diagnoses included hemiplegia and hemiparesis following stroke affecting right dominant side, dementia without behavioral disturbance, and chronic pain. [...]

Inspectors wroteBased on observation, staff and resident interviews, and record review, the facility failed to ensure medications were not left out at bedside without secure storage and supervision from the nurse. This affected two residents (#28 and #146) of two reviewed for medication storage. Facility census was 92.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Resident #17 was properly issued a 30 day discharge notice and failed to ensure Resident #17 reviewed his discharge summary. This affected one resident (Resident #17) of four residents reviewed for discharges. Findings Include: Resident #17 was admitted to the facility on [DATE]. His diagnoses were alcoholic cirrhosis of liver without ascites, hypertension, anorexia, other idiopathic peripheral autonomic neuropathy, muscle weakness, and difficulty walking. According to his medical documentation, he was his own responsible party with a family member as the first emergency contact. Review of Resident #17's 30 day discharge letter, revealed the letter was generated on 01/09/20 due to the facility stating they were not able to meet the residents needs, and he was to be discharged on 02/10/20. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that the state ombudsman was notified of resident discharges. This affected three residents (Resident #17, Resident #88, and Resident #89) of four resident discharges reviewed. Findings Include: Review of Resident #17 medical records revealed he was immediately discharged from the facility on 02/24/20, after he was arrested. Review of Resident #88 medical records revealed she was discharged from the facility on 07/16/21, when she was sent to the hospital. Finally, review of Resident #89 medical records revealed she was discharged home immediately on 08/10/21. While reviewing all three resident medical records, there was no evidence that the facility sent the discharge information to the state long term care ombudsman office. Interview with Administrator on 09/30/21 at 1:15 P.M. [...]

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to ensure two residents (Residents #1 and #60) had their hair washed as scheduled and failed to ensure one resident (Resident #62) was shaved per preference. The affected three residents (Residents #1, #60, and #62) of five residents reviewed for activities of daily living (ADL's). Findings Include: 1. Review of the medical record for Resident #1 revealed an original admission date of 01/21/21 and a readmission date on 09/16/21 with medical diagnoses including addisonian crisis, stage III chronic kidney disease, other specified sepsis, muscle weakness, type II diabetes mellitus, encephalopathy, disorientation, adult failure to thrive, low back pain, fibromyalgia, rheumatoid arthritis, anxiety disorder, major depressive disorder, and other abnormalities of gait and mobility. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide activities according to Resident #44 and Resident #338's preferences. This affected two residents (Resident #44 and Resident #338) of two residents reviewed for activities that meet the interest and needs of each resident.

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to ensure a splint was placed on a resident's (Resident #46) left hand as ordered. The deficient practice affected one (Resident #46) of one reviewed for limited range of motion (ROM). Findings Include: Review of the medical record for Resident #46 revealed an admission date on 06/22/18 with medical diagnoses including cerebral infarction, cognitive communication deficit, aphasia following unspecified cerebrovascular disease, weakness, other lack of coordination, and muscle weakness. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/19/21, revealed the resident was rarely or never understood. Per staff assessment, the resident had severely impaired cognition. [...]

Inspectors wroteBased on medical record review, observation, interview, and facility policy and procedure, the facility failed to ensure fall interventions were in place and revised as needed. This affected two residents (Resident #25 and Resident #62) out of four residents reviewed for falls. Findings Include: 1. Review of the medical record for Resident #25 revealed an admission date of 05/17/11 with the diagnoses of falls, ataxia, lack of coordination and gait abnormalities. Review of Resident #25's Minimum Data Set (MDS) assessment, dated 07/16/21, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and she required extensive one assistance for bed mobility, dressing, toilet use and transfers, independence for locomotion via wheelchair, and supervision of one assist for personal hygiene. Review of Resident #25's fall investigations revealed the following: A. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident had physician orders for the use of respiratory equipment referred to as a Continuous Positive Airway Pressure (CPAP) machine. This affected one resident (Resident #340) of two residents reviewed for respiratory care.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to communicate and review dialysis labs for Resident #82. This affected one resident (Resident #82) of three residents reviewed for dialysis services.

Inspectors wroteBased on resident and staff interview, review of laboratory results, and record review, the facility failed to notify the physician or certified nurse practitioner (CNP) of new urinalysis test results for Resident #1. This affected one resident (Resident #1) of one resident reviewed for notification of change. Findings Include: Review of the medical record for Resident #1 revealed an original admission date of 01/21/21 and a readmission date on 09/16/21 with medical diagnoses including addisonian crisis, stage III chronic kidney disease, other specified sepsis, type II diabetes mellitus without complications, and urinary tract infection (UTI) with site not specified. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21, revealed Resident #1 had mildly impaired cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Resident #86's medical record reflected an accurate diagnosis for physician ordered medication. This affected one resident (Resident #86) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control after a blood glucose check and during insulin administration. This affected one resident (Resident #80) out of two residents observed during medications administration for blood glucose checks and insulin administration. Findings Include: Review of the record for Resident #80 revealed an admission date of 06/01/21 and the diagnoses of diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), anxiety, depression, insomnia, atrial fibrillation, opioid dependency, and chronic pain. The resident had no documented evidence of a transmissible disease. Review of Resident #80's Minimum Data Set (MDS) assessment. [...]