Adel Acres

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 5 surveys, and staff interview, the facility failed to correct their own deficiencies for 2 of 2 areas of concern. The facility reported a census of 41 residents. Findings include:The facility had the following concern identified at the current revisit survey that had been cited at the previous 4 recertification surveys: a.Infection Prevention and Control The facility had the following concern identified at the current revisit survey that had been cited at the previous recertification survey and the previous complaint survey:b.Services Provided Meet Professional StandardsThe undated facility Quality Assurance and Performance Improvement (QAPI) Plan documented the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility will develop and implement appropriate plans of action to correct identified quality deficiencies and act on available data to make…

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

Based on observations, staff interviews, and policy review, the facility failed to follow Enhanced Barrier Protection (EBP) and appropriately discard soiled wound care dressings for 1 of 2 residents reviewed for wound care. The facility reported a census of 40.Findings include:The Minimum Data Set (MDS) Assessment completed on 3/10/26 revealed Resident #35 with a Brief Interview for Mental Status score of 8, indicating a moderate cognitive impairment. Diagnoses include peripheral vascular disease (circulation disorder commonly in the legs and feet) . The MDS noted the presence of a surgical wound, requiring wound care, as well as a foot infection. The Care Plan, with a Target Date of 6/5/26, stated Resident #35 required EBP related to the presence of a right ankle wound. Interventions include using EBP during high contact activities. The Order Summary Report, obtained on 3/25/26, listed the use of EBP related to right ankle wound. The report also noted the following wound care order for an abscess to the right heel surgical wound: 1. Soak one gauze packing strip in betadine; 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to ensure the resident had a physician that would provide orders and respond promptly to notification of a resident's elevated blood sugars (BS), abnormal blood lab work, and intravenous (IV) medication for infection not able to be administered for 1 (Resident #1) of 3 residents reviewed. The facility reported a census of 42 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/9/25, included diagnoses of diabetes, septicemia (presence of bacteria in the blood stream), renal (kidney) failure, and aphasia (impairment in a person's ability to comprehend or formulate language). The MDS identified the resident was receiving insulin and hypoglycemic medication (medication for diabetes to lower the blood sugar levels). The MDS indicated the resident had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment for decision-making.Resident's hospital Discharge summary dated [DATE]…

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

Based on direct observation, staff interview, facility documentation, and facility policy review, the facility failed to implement measures to ensure safety for each resident identified at risk of injury to themselves. The facility reported a census of 44. Findings include: The significant change Minimum Data Set (MDS) for Resident #7, dated 03/27/2025, documented the resident's Brief Interview for Mental Status score (BIMS) was documented as 02, indicating severely intact cognition. It also documented the following relevant diagnoses: hemiplegia or hemiparesis (partial or full paralysis), anxiety disorder, bipolar disorder, and cognitive communication deficit. A continuous direct observation on 04/06/2025 from 10:06 AM until 10:34 AM revealed the shower room door of the South Hall was open, the floor was visibly wet and the shower was still running. During the observation several residents were walking up and down the hall, with Resident #7 ambulating extremely slowly via wheelchair. During the observation surveyors positioned themselves near the door to the shower room to prevent…

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

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 44. Findings include: A direct observation on 04/06/2025 from 12:21 PM until 01:31 PM revealed the following: At 12:22 PM the Dietary Manager touched the top of the plate while she served food to a resident. At 12:27 PM Staff B, Licensed Practical Nurse (LPN) placed a clothing protector on a resident, making direct contact with the resident's skin, then served the resident plate while touching the top of the plate without performing hand hygiene. At 12:32 PM Staff B, LPN, again made direct contact with another resident, did not perform hand hygiene, and then began feeding two residents at the same time with no witnessed hand hygiene performed while switching from one resident to another. The Dietary manager was also seen continuing to serve resident meals holding the plates with her thumb near resident food. At 12:35 PM the Dietary manage made direct contact with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, staff competency checklist and policy review, the facility failed to follow enhanced barrier precautions for 1 of 4 residents sampled and required enhanced barrier precautions and 1 of 1 residents observed for catheter care (Resident #26). The facility staff also failed to use a barrier when emptying the catheter. The facility staff also failed to follow infection control practices for 1 of 4 residents observed during cares (Resident #30). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had diagnoses of neurogenic bladder, urinary retention, diabetes, and non-Alzheimer's dementia. The MDS indicated the resident had an indwelling catheter. The Care Plan revised 5/20/24 revealed Resident #26 had a suprapubic catheter and chronic urinary tract infections. The Care Plan directed staff to utilize a gown and gloves for enhanced barrier precautions (EBP) during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interviews, and policy review the facility failed to carry out therapy recommendations and provide restorative exercises for 1 of 3 residents reviewed for rehabilitation services and/or limited range of motion (Resident #17). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had diagnoses of cerebrovascular accident (CVA) (stroke), lymphedema and a chronic non-pressure ulcer on his buttock. The MDS recorded the resident had a Brief Interview for Mental Status score of 15, indicating cognition intact. The MDS documented the resident had impaired range of motion (ROM) on one side of his body. The resident required substantial to maximum assistance for toileting, and partial to moderate assistance for transfers and ambulating 10 feet. The MDS recorded the resident had physical therapy (PT) services 7/21/23 to 8/18/23, and no days of restorative nursing program…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, manufacturer recommendations, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 30 opportunities for error resulting in an error rate of 6.67 % (Residents #19 and #22). The facility identified a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a diagnosis of diabetes. The MDS documented the resident took insulin 6 of 7 days during the look-back period. The Care Plan initiated 3/26/25 revealed the resident had diabetes. The Care Plan directed staff to administer diabetes medication as ordered by the physician. The Order Summary revealed to inject Novolog flexpen 100 unit/ milliliter (ml) subcutaneous (SQ) after meals and at bedtime related to Type 2 Diabetes Mellitus as per sliding scale: if 150 - 199 = 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 10; 350 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, manufacturer's instructions, and policy review the facility failed to administer insulin according to the physician's orders for sliding scale insulin and per manufacturer instructions to ensure the proper amount of insulin administered for one of two residents observed who received insulin during medication pass (Resident #19). The facility failed to update sliding scale orders inside the plastic bin with blood sugar supplies for one of seven residents who took insulin. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a diagnosis of diabetes. The MDS documented the resident took insulin 6 of 7 days during the look-back period. The Care Plan initiated 3/26/25 revealed the resident had diabetes. The Care Plan directed staff to administer diabetes medication as ordered by the physician and educate caregivers on the correct protocol for glucose monitoring and…

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

Based on observation, menu review, record review, and staff interviews, the facility failed to serve the appropriate portions for two of two residents who received pureed diets (Resident #5 and #25). The facility reported a census of 44 residents. Findings include: The facility's Fall/Winter Week 3 Menu for Monday lunch identified chicken, the vegetable of the day (peas), and a dinner roll to be served as part of the planned pureed textured diet for the lunch meal served on 4/7/25. The facility's Resident Summary Report listing each resident's diet identified two residents on a pureed texture diet. During observation on 4/7/25 at 11:37 AM, Staff E, Dietary Cook, reported two residents on a pureed diet, but she planned to make one additional serving. Staff E placed three dinner rolls and three chicken breasts into a robot coupe container, added some chicken broth, and blended the contents together. Staff C poured the contents into a measuring cup and reported a total of two cups. Staff C then poured the pureed contents into a metal pan on the steam table. On 4/7/25 at 11:44 AM Staff…

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

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to protect the personally identifiable information of residents for 1 of 14 residents reviewed (Resident #96). The facility reported a census of 44. Findings include: The Care plan for Resident #96, completed on 04/07/2025, identified the resident had received a skin graft after cancer surgery. It did not document how often or how to bathe the resident. A direct observation on 04/06/2025 at 10:30 AM revealed a note, taped to the staff schedule and facing the dining room accessible to all visitors in the facility, where Resident #96's care information was posted. It documented Resident #96 had a skin graft, currently had a drainage port, and that the resident was limited to only receiving bed baths due to the skin issues. It identified Resident #96 by full name. A direct observation on 04/06/2025 at 01:31 PM revealed an unidentified staff member take the note down from the staff schedule after lunch dining service. In an interview on 04/09/2025 at 12:23 PM with Staff…

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

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 42 residents. Findings included: On 12/16/24 at 9:03 AM, two medication carts were observed in front of the nurses' station and facing the dining room Staff A, Certified Medication Aide (CMA) was observed preparing medications at one of the medication carts. She took medications into the dining room with her back positioned toward both medication carts. Both medication carts were observed unlocked with no other staff present. At 9:06 AM, Staff B, Registered Nurse (RN) walked up to the first laptop, put something in the medication cart, then locked it and walked away. At 12:40 PM, Staff B, RN, stated the medication carts should be locked when staff walks away from them. On 12/17/24 at 8:49 AM, Staff A, CMA stated the medication cart should be locked when staff walks away from it and it is never ok to leave it unlocked at that time. She stated she just forgot to lock it on 12/16/24. On 12/17/24 at…

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

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 42 residents. Findings include: On 12/16/24 at 9:03 AM, two (2) unlocked laptops were observed sitting on medication carts. Staff A, Certified Medication Aide (CMA) walked away from one of the laptops, turned her back to both, and gave medication to a resident. Both laptop screens faced an occupied dining room and had multiple residents' information visible. At 9:06 AM, Staff B, Registered Nurse (RN) walked up to the first laptop, put something in the medication cart, then locked the laptop screen. At 12:50 PM, Staff B, RN, stated when staff walks away from the medication cart, the laptop screen and cart should be locked. She also stated if staff's back is toward the laptop, the cart and laptop should be locked. On 12/17/24 at 8:49 AM, Staff A, CMA stated the medication cart should be locked when staff walks away from it and it is never ok to leave it unlocked at that time. She stated she just forgot to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on direct observation, clinical record review, staff interview, and policy review, the facility failed to grant a resident the right to choose to wear personal clothing for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 42. Findings include: The Annual Minimum data set (MDS) for Resident #5, dated 12/22/2023, included the following relevant diagnoses: diabetes mellitus (diabetes), cerebrovascular accident (stroke), above the knee amputation of the left leg. It documented the resident was dependent on staff for dressing his lower body and required moderate assistance to dress his upper body. It further documented the resident was dependent on staff for all transfers. The Quarterly MDS for Resident#5 documented that a 14 out 15 score for the Brief Interview for Mental Status, which indicated intact cognitive skills. The Care Plan for Resident #5, last revised on 11/14/2024, documented Resident #5 required staff assistance to dress. It also advised readers to document observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to implement the resident's Care Plan for 1 of 3 residents who fell (#3). The facility reported a census of 42 residents. Findings include: The Annual Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), cerebral infarction due to embolism of middle cerebral artery (stroke caused by a blood clot), intracerebral hemorrhage (stroke caused by brain bleed), hemiplegia (one-sided paralysis), aphasia (loss of ability to understand or express speech), and Chronic Obstructive Pulmonary Disease (COPD). It also revealed the resident was independent with oral hygiene, required setup assistance with personal hygiene, supervision with eating and toileting hygiene, moderate assistance with upper body dressing, maximum assistance with bathing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to provide assessment and interventions for 1 of 3 residents who fell (#3). The facility reported a census of 42 residents. Findings include: A Facility reported Incident revealed Resident #3 fell on [DATE] at 2:12 AM. The Annual Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), cerebral infarction due to embolism of middle cerebral artery (stroke caused by a blood clot), intracerebral hemorrhage (stroke caused by brain bleed), hemiplegia (one-sided paralysis), aphasia (loss of ability to understand or express speech), and Chronic Obstructive Pulmonary Disease (COPD). It also revealed the resident was independent with oral hygiene, required setup assistance with personal hygiene, supervision with eating and toileting hygiene,…

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

Based on observations, staff interview, and policy review the facility failed to implement the infection control policy as staff failed to perform hand hygiene during medication administration for one (1) resident (#4) and between feeding two (2) residents (#10, #11). The facility staff also failed to clean a mechanical lift between two residents' use (#6, #9). The facility reported a census of 42 residents. Findings include: 1) On 12/16/24 at 9:09 AM, Staff A, Certified Medication Aide (CMA) prepared Resident #4's medications at a medication cart. One (1) pill fell into the top drawer and Staff A grabbed it with her bare hand and placed it back into the resident's medication cup. She then took it to the resident. At 12:40 PM, Staff B, Registered Nurse (RN) stated if a medication fell and landed anywhere outside the resident's cup, it should be discarded and replaced. She said it was not ok to grab the pill and put it in the resident's cup and give it to them. At 12:45 PM, Staff A, CMA stated if a med fell anywhere other than the resident's medication cup, it should be discarded.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, observation, staff interview, and facility policy review, the facility failed to follow physician orders for 1 of 3 residents reviewed for medication orders (Resident #1). The facility reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. The MDS revealed the Resident Mood Interview score of 14 which indicated moderate depression. The MDS revealed the resident did not have any behaviors. The MDS revealed the resident is maximal assist for eating and dependent level of care for oral hygiene, toileting hygiene, bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, roll left and right, and transfers. The MDS reflected the resident always incontinent of bowel and bladder. The MDS documented diagnoses that included: Heart Failure, Hypertension, End-Stage Renal Disease,…

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

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1 - December 31) review, facility staffing reports review, employee time cards review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 40 residents. Findings include: The PBJ Staffing Data Report run date 5/15/24 triggered for Excessively Low Weekend Staffing - submitted weekend staffing data is excessively low, and failed to have licensed nursing coverage 24 hours/day - 4 or more days within the quarter with <24 hours/day licensed nursing coverage with specific infraction dates. The report reflected 19 dates with failure to provide 24 hour/day nursing coverage. Review of Facility Daily Assignment Sheets for each day of the months of October, November and December staffing revealed staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. The documents identified the CNA coverage of shifts by the Director of Nursing (DON),…

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

Based on observations, staff interview, and policy review, the facility failed to ensure dietary staff practiced food safety procedures when preparing and serving resident meals to reduce the risk of cross contamination and foodborne illness. The facility reported a census of 40 residents. Findings include: During dining observation on 5/20/24 at 12 PM, Staff A, dietary aide, observed wearing a T-shirt with numerous small holes on the front as well as a large, wet stain covering approximately 25%. No apron or clothing protector seen. During kitchen observation on 5/22/24 from 1130 am-1230 am, Staff B, dietary cook, prepared hamburger patties while pureeing lunch items. When she obtained hot water for a puree item, she was seen flipping the hamburger patties as walking by and then resumed pureeing. No hand hygiene was observed in-between these tasks. Staff B, dietary cook, also failed to obtain a final cooking temperature prior to serving the hamburger to residents. Staff B, dietary cook, worked the steam table/prepared resident lunch plates. She was observed coughing and/or sneezing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to assure resident's or their representatives completed the Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN)/clarified their wishes for 2 of 3 residents reviewed (Resident #10 and #37). The facility reported a census of 40 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #10 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The SNF ABN form notified Resident #10 beginning on 2/9/24 he may have to pay out of pocket for (skilled) care. The resident signed the form, but the rest of the writing was someone else's. The resident did not choose an option for how he wanted to proceed. The clinical record lacked documentation that the facility asked Resident #10 about choosing an option. 2) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe…

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

Based on personnel file reviews, staff interviews, and policy review the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 1 of 5 employees reviewed (Staff C). The facility census was 40. The personnel file for Staff C, Certified Nursing Assistant (CNA), reflected a rehire date of 3/11/24. The file lacked the background check. On 5/22/24 at 1:37 PM the Business Office Manager reviewed Staff C's personnel file and confirmed the only Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License in the file was dated 10/24/23. The staff completed an online verification via the facility's The Single Contact Repository (SING) account for Staff C's background check. The Business Office Manager acknowledged the facility failed to complete a background check for Staff C prior to rehire. The staff stated the facility practice was only the Business Office Manager was to complete the background checks. The background checks would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASSR) evaluations for a change in diagnoses or treatment for 2 of 4 residents reviewed (Resident #40 and #18). The facility reported a census of 40. Findings include: 1) The Quarterly Minimal Data Set (MDS) dated [DATE] documented Resident #40 had a Brief Interview for Mental Status (BIMS) of 1 indicating a severe cognitive impairment. The MDS further documented the resident had diagnoses including depression, anxiety, and a psychotic disorder (other than schizophrenia). The MDS reports the use of high-risk medications including an antianxiety, antidepressant, and antibiotic medications. Current medication orders, as of 5/23/24, include Lamotrigine 25 milligram (mg) daily related to unspecific psychosis (medication initiated on 3/5/24), Sertraline HCl 50mg daily related to anxiety disorder and depression (medication initiated on 2/2/24), Lorazepam 0.5mg three times daily related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to assure appropriate care of a catheter for 1 resident reviewed with a catheter (Resident #37). The facility reported a census of 40 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident had an indwelling urinary catheter. The resident had diagnoses including obstructive uropathy (blockage in urinary tract). The Care Plan with a goal target date of 10/23/24 identified the resident had bowel incontinence related to immobility. The interventions included checking the resident every two hours and assisting with toileting as needed, providing pericare after each incontinent episode, and utilizing briefs for dignity. The Care Plan revised 5/15/24 identified the resident required an indwelling catheter due to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview the facility failed to assure residents received the recommended dietary interventions for a history of significant weight loss for 1 of 3 residents reviewed (Resident #37). The facility reported a census of 40 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident had diagnoses malnutrition. The Care Plan revised 9/5/23 identified the resident had a potential nutritional problem related to depression, hypertension. The interventions included the resident ate in the dining room (DR), and the registered dietician to evaluate and make diet change recommendations as needed. An EHR Supplement Orders dated 5/22/24 documented Resident #37 had Supplement 2.0, 3 times a day for weight loss. A Nutritional Evaluation dated 5/15/24 documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to offer and complete the Veterans Administrator form for 1 of 3 residents reviewed for VA (Resident #30). The facility failed to file the residents paperwork for eligibility for 1 of 3 residents reviewed for VA (Resident #22). The facility reported a census of 40 residents. Findings include: 1. The Quarterly Minimum Data Set, dated [DATE] documented Resident#30's admission date was 11/28/23. The facility's Action Summary, revealed Resident #30 admitted to facility on 11/28/2023. The VA paperwork was not found for Resident #30. 2. The facility's Action Summary, revealed Resident #22 admitted to facility on 8/1/2023. The paperwork was not submitted to the VA for eligibility status for Resident #22. On 05/23/24 10:55 AM the Administrator acknowledged unable to locate missing documentation for Resident #30. On 05/23/24 12:02 PM the Administrator acknowledged that paperwork was not submitted to the VA for eligibility for Resident #22. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to provide care in a manner to prevent infection for 2 of 13 residents reviewed (Resident #30 and #37). The facility reported a census of 40 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #30 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident's diagnoses included a stroke. The Care Plan revised 5/14/24 identified the resident had potential/actual impairment to skin integrity of the buttock and arms related to fragile skin, incontinence, limited mobility moisture associated skin damage to the right and left buttock and sacrum. Interventions included providing peri care after each incontinent episode. On 5/21/24 at 11:45 a.m. Staff I Registered Nurse (RN), Staff E Certified Nursing Assistant (CNA) , Staff F CNA and Staff G CNA went in to change the resident before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, hospital clinical record review, hospital images, staff interviews, and policy review, the facility failed to identify a resident with pressure ulcers/wounds and to assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of ulcers/wounds for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness…

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

Based on the review of the Quality Assurance Performance Improvement (QAPI) sign in sheets, staff interview, and policy review, the facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Specifically, the Director of Nursing (DON)/Infection Preventionist(IP) failed to be present for 2 of the 4 quarterly meetings reviewed. The facility reported a census of 45 residents. Findings include: Review of the QAPI meeting sign-in sheets from April 2023 to March 2024, provided by the Administrator on 4/2/24, revealed the DON/Infection Preventionist attended the meeting on 4/18/23 and 3/12/24. On 4/4/24 at 10:58 AM, the Administrator acknowledged and verified the QAPI sign in sheets lacked the DON/IP signatures except for the months of April 2023 and March 2024. The facility policy titled QAPI last reviewed on 8/20/20 documented the QAA will meet monthly and include the following team members: Administrator, DON, Medical Director, IP, Social Services Designee, Activities Director, Environmental Services, Dietary Manager, Medical…

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