Caring Acres Nursing and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to develop a Comprehensive Person-Centered Care Plan that included specialized services or specialized rehabilitative services the nursing facility would provide as a result of Preadmission Screening and Record Review (PASARR) recommendations for 2 of 4 residents reviewed (Resident #12 and Resident #3). The facility reported a census of 24 residents. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified an admission date of 9/11/24. The MDS indicated Resident #12 didn't have a Preadmission Screening and Resident Review (PASRR) level II status. The Notice of PASRR level II Outcome dated 12/23/26, reflected Resident #12 received a PASRR approval of Level II with recommendations for specialized services of ongoing psychiatric medication management, individual therapy, and rehabilitative services. The Care Plan revised 12/19/25 lacked a focus, goals, or interventions for the PASRR level II status…

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 interview, and policy review the facility failed to revise and implement care plans for 2 of 3 residents reviewed (Residents #5 and #9). The facility reported a census of 24 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #5 used an antipsychotic, antianxiety, and antidepressant medications during the 7-day lookback period. Resident #5's Clinical Physician Orders reviewed 2/10/26 included the following medication orders:a. Vraylar Oral Capsule 1.5 MG (antipsychotic medication). Give 1.5 capsules by mouth one time a day.b. Alprazolam Oral Tablet 1 MG (antianxiety medication). Give 1 mg by mouth three times a day.c. Fluoxetine HCl Oral Capsule 40 MG (antidepressant medication). Give 40 mg by mouth one time a day.Resident #5's Care Plan revised 1/26/26 lacked the side effects to monitor while taking high risk medications. 2. Resident #9's MDS assessment dated [DATE] reflected they used an antidepressant 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 observations, staff interview, and policy review the facility failed to serve food under sanitary conditions to prevent foodborne illness during one of one meal observed. The facility reported a census of 24 residents. Findings include:On 2/11/26 starting at 12:00 PM, observed Staff D, Cook, wash their hands, apply gloves and start lunch service. With their gloved hands, Staff D touched spatulas, scoop handles, the counter, food containers. With the same gloved hands, Staff D touched a peanut butter and jelly sandwich to place it on a plate then sent the plate to a resident. Staff D removed the gloves, wash their hands, and applied new gloves. With the new gloves, Staff D touched the glove box, utensils, ladle, scoop handles, and countertop. Without completing hand hygiene or changing their gloves, Staff D touch another sandwich and placed it on a plate for a resident. On 2/11/26 at 2 PM, the Dietary Manager stated she expected the staff to use the gloves 1 time use when touching food and to not touch other items before touching food items. The facility's Bare Hand Contact…

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, clinical record review, staff interview, and policy review the facility failed to maintain infection control practices with catheter care and hand hygiene for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 24 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified they had an indwelling urinary catheter (tube into the bladder to drain urine from the bladder). The MDS included diagnoses of non-Alzheimer's Dementia and a stroke. On 2/10/26 at 1:39 PM, observed Staff C, Certified Nurse Aide, wearing gloves, emptied Resident #2's catheter bag, clean the drain port on the catheter bag, and empty the urine into the toilet. Without completing hand hygiene or changing their gloves, Staff C touched the uncovered roll of paper towels sitting on top of the cabinet and using both gloved hands tore off a paper towel and placed the towel in a graduate container. Staff C removed her gloves, washed her hands, and touched the same roll…

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 previous Centers of Medicare and Medicaid Services (CMS) from 2567 review, staff interviews, and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 31 residents.Findings Include: A review of the Department of Inspections, Appeals and Licensing website revealed the facility had repeated deficient practices identified during complaint investigations from 8/3/2023 to 6/19/2025. The repeat deficiencies cited include:-8/3/2023 during a compliant investigation: 609 Failure to Report-6/24/2024 during a complaint investigation: 610 Failure to Investigate-8/2/2024 during a complaint investigation: 609 Failure to Report-6/19/2025 during a complaint investigation: 609 Failure to ReportOn 10/14/2025 at 12:11 PM the Administrator stated he came started at the facility a week ago on 10/6/2025. He stated to prevent repeat deficiencies they would hold monthly all staff meetings, as well as mandatory meetings. If staff are unable to attend they have 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.

Based on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to timely report an allegation of abuse to the appropriate management staff member for 1 of 5 (Resident #1) residents reviewed. The facility reported a census of 31 residents.Findings include:According to the admission Minimum Data Set (MDS) assessment with a reference date of 8/25/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. Resident #1 had impairments to bilateral lower and upper extremities and utilized a motorized wheelchair. Resident #1 was frequently incontinent of urine and bowel, dependent on staff for toileting hygiene and rolling from left to right. The following diagnoses were listed for Resident #1: cerebral palsy, anemia, neurogenic bladder, anxiety, depression, bipolar, post-traumatic stress disorder (PTSD), nephrotosis, and bactermia.The Care Plan Focus Area with a revision date o 8/25/2025 documented Resident #1 had an Activities of Daily Living (ADL)…

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 facility investigative file review, resident and staff interviews and facility policy review the facility failed to complete a thorough investigation, for 1 of 5 residents reviewed (Resident #1), when a resident reported money was missing from her room. The facility reported a census of 31 residents.Findings include:According to the admission Minimum Data Set (MDS) assessment with a reference date of 8/25/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The following diagnoses were listed for Resident #1: cerebral palsy, anemia, neurogenic bladder, anxiety, depression, bipolar, post-traumatic stress disorder (PTSD), nephrotosis, and bactermia.On 10/10/2025 at 10:43 AM Resident #1 stated she would keep her money wrapped in two red socks in a zip lock bag located in her top right drawer of the dresser that was located to the left of her bed. When she noticed $90 was missing she notified staff and the facility replaced her money. Since then she puts her money in a lock box.Review of the…

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, interviews, electronic health record (EHR) reviews, and facility policy review the facility failed to provide dignity to 3 of 7 residents (Resident #4, Resident #6, Resident #7). The facility failed to provide dignity to the residents as demonstrated by a staff telling a resident to sit down when the resident indicated the need to use the bathroom, a staff using discriminatory words towards a resident and in front of other residents, and a resident sitting exposed in a common area with other residents. The facility reported a census of 24 residents. Findings Include: 1. The Minimum Data Set (MDS) for Resident #4, dated 4/16/25 identified a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severe cognitive impairment. The resident had diagnoses of Non-Alzheimer's Dementia, anxiety disorder, depression, bipolar disorder, and post traumatic stress disorder (PTSD). Resident #4's Care Plan dated 6/19/25 revealed a Focus Area of Activities of Daily Living (ADL) self-care performance deficit. Interventions for staff use included the resident required…

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, facility investigative file review, employee file review, and policy review the facility failed to ensure 1 of 5 residents reviewed (Resident #4) was free from verbal abuse. The facility reported a census of 24 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE], Resident #4 had a Brief Interview of Mental Status (BIMS) score of 6. A BIMS score of 6 suggested mild cognitive impairment. The MDS documented she was independent with mobility but required supervision or touching assistance to walk 10 feet, 50 feet with two turns, and 150 feet. Resident #4 was always continent of urine and frequently incontinent of bowel. The following diagnoses were listed for Resident #4: dementia, anxiety, depression, bipolar, post-traumatic stress disorder (PTSD), atrial fibrillation, irritability and anger, and cognitive communication deficit. The Care Plan focus area with an initiation date of [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility investigative file review, employee file review, staff interviews, and facility policy review the facility failed to timely report an allegation of abuse to the appropriate management staff member. The facility reported a census of 24 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE], Resident #4 had a Brief Interview of Mental Status (BIMS) score of 6. A BIMS score of 6 suggested mild cognitive impairment. The MDS documented she was independent with mobility but required supervision or touching assistance to walk 10 feet, 50 feet with two turns, and 150 feet. Resident #4 was always continent of urine and frequently incontinent of bowel. The following diagnoses were listed for Resident #4: dementia, anxiety, depression, bipolar, post-traumatic stress disorder (PTSD), atrial fibrillation, irritability and anger, and cognitive communication deficit. The Care Plan focus area with an initiation date of…

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 clinical record review, staff interviews and facility policy review the facility failed to sign out an as needed (PRN) medication when given and follow up to ensure the PRN was effective for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 24 residents. Findings include: According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 3/7/2025 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented he was frequently incontinent of urine and bowel. The MDS indicated he required partial/moderate assistance with toileting hygiene and transfers. The following diagnoses were listed for Resident #1: Parkinson's Disease, coronary artery disease and diabetes mellitus. The Care Plan focus area with an initiation date of 2/4/2025 documented Resident #1 had Activities of Daily Living (ADL's) performance deficit related to activity intolerance. The Care Plan indicated Resident #1 required the assistance of one staff to move between surfaces…

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 facility policy review the facility failed to properly transfer Resident #1 from the floor to her bed after she sustained a fall with complaints of hip pain. The facility reported a census of 24 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE], Resident #4 had a Brief Interview of Mental Status (BIMS) score of 6. A BIMS score of 6 suggested mild cognitive impairment. The MDS documented she was independent with mobility but required supervision or touching assistance to walk 10 feet, 50 feet with two turns, and 150 feet. Resident #4 was always continent of urine and frequently incontinent of bowel. The following diagnoses were listed for Resident #4: dementia, anxiety, depression, bipolar, post-traumatic stress disorder (PTSD), atrial fibrillation, irritability and anger, and cognitive communication deficit. The Care Plan focus area with an initiation date of [DATE] 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.

Based on facility document review and staff interview the facility failed to accurately submit the required Payroll Based Journal (PBJ) quarterly report. The facility reported a census of 25 residents. Findings include: The 2024, 4th quarter PBJ report indicated that the facility had low weekend staffing, low Registered Nurse (RN) coverage for 8 consecutive hours/day, concerns regarding Licensed Nurses coverage 24 hours a day and concerns regarding their 1-star staffing rating. On 2/17/25 at 2:00 PM the Administrator said that she has only been the Administrator since the beginning of January and the previous leaders told her that the reason the PBJ showed low staffing was because they failed to include the Agency staff hour in the report. She said that they were trying to figure out those hours and to fill in the blanks. On 2/20/25 at 9:00 AM the Administrator said that they did not have a policy on submission of information for quarterly PBJ reports.

Based on staff interview, and policy review the facility failed to properly establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 25 residents. Findings include: Review of the facility policy updated 1/24 titled, QAPI Policy lacked a description of how the facility would identify, report, track, investigate and analyze adverse events or problem-prone concerns. The policy also lacked a description as to how the facility obtains and uses any feedback from resident representatives to identify high-risk or problem prone issues. The policy lacked a description of how the facility monitored the effectiveness of its performance improvement activities to ensure improvements are sustained. On 2/20/25 at 9:28 AM the Interim Administrator acknowledged QAPI had only been completed for the month of 4/24 and 6/24. The Interim Administrator acknowledged the QAPI policy lacked a description of how the facility would identify, report, track, investigate and analyze adverse events or problem-prone…

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 policy review, document review, and staff interview the facility failed to maintain records of quality assurance meetings for 3 of 4 quarters reviewed. The facility reported a census of 25 residents. Findings include: Review of a facility provided document titled, QA&A (Quality Assessment and Assurance) Committee Meeting Facility dated 4/4/24 and 6/6/24 revealed all necessary members attended these meetings from the same quarter. No further quarterly documentation was provided for the next three quarters. On 2/20/25 at 9:28 AM the Interim Administrator acknowledged the QAA committee had only been completed for the month of 4/24 and 6/24 from the same quarter. The Interim Administrator stated the facility's expectation was that the QAA committee would meet at a minimum of quarterly. Review of policy updated 1/24 titled, QAPI (Quality Assessment and Performance Improvement) Policy documented the QAPI program consisted of monthly / quarterly meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and clinical record review the facility failed to implement adequate infection control measures to prevent the spread of pathogens. Staff failed to use hand hygiene while assisting Residents #17, #1 and #10 with toileting. Laundry staff failed to cover personal items while transferring to rooms, and frequently left full garbage bags on the floor. The facility reported a census of 25 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #17 was admitted to the facility on [DATE]. She had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive impairment). The resident required substantial assistance with shower/bath, dressing hygiene, sit to stand and toileting transfer. Her diagnoses include cancer, anemia, and non-Alzheimer's dementia. The Care Plan updated on 2/10/25, showed that Resident #17 had terminal prognosis and chose Hospice care. She was dependent on staff with a wheelchair for ambulation. Resident #17…

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 Electronic Health Records (EHR) review, observations, resident interviews and staff interview the facility failed to provide the residents with a comfortable homelike environment by not providing warm water in the residents rooms. The facility reported a census of 25 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 2/17/25 at 2:05 PM Resident #6 stated the water in her sink in her room was not ever hot. Resident #6 stated she wanted the water to be hot for washing her hands and the water should be hot. Resident #6 stated the staff are aware of the issue. 2. The MDS dated [DATE] for Resident #12 documented a BIMS of 15 indicating no cognitive impairment. On 2/17/25 at 12:59 PM Resident #12 stated the water in his room took a long time to get warm and then it never does actually get hot at all. Resident #12 stated the staff are aware of the problem. 3. The MDS…

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 observations, resident interviews, staff interviews, clinical record review and policy review the facility failed to ensure that staff followed physicians' orders for 4 of 16 residents reviewed. Resident #18 had several pressure ulcers with treatment orders to be completed twice daily. Staff failed to complete the treatments as ordered. Staff failed to observe medication administration for Residents #14 and #20, and Staff J was alerted by a resident that she was about to give the medication for Resident #26 to the wrong person. The facility reported a census of 25 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) The Care Plan initiated on 12/12/24, showed that Resident #18 had self-care deficits related to trauma. He was totally dependent on staff for repositioning and had pressure ulcers. Staff were directed to administer treatment as ordered and monitor for effectiveness.…

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 observations, staff interviews clinical record review and policy review the facility failed to implement interventions to prevent accidents and hazards for 4 of 16 residents reviewed. Residents #10 and #25 were identified as elopement risk and had Wander Guard alarm bracelets. Staff failed to ensure that the alarms were working by conducting daily checks. Staff also failed to provide safe transfer techniques with Resident #1 and #17. The facility reported a census of 25 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #17 was admitted to the facility on [DATE]. She had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive impairment). The resident required substantial assistance with shower/bath, dressing hygiene, sit to stand and toileting transfer. Her diagnoses include cancer, anemia, non-Alzheimer's dementia, The Care Plan updated on [DATE], showed that Resident #17 had a terminal prognosis and chose Hospice care. She was dependent 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.

Based on observation, interview and record review the facility failed to ensure that competent and trained staff were providing resident care. The facility reported a census of 25 residents. Findings include: Review of the nursing schedule from 2/2/25 - 2/15/25 revealed that 5 out of the 7 nurses on the schedule were not facility staff but contracted Agency Staff (AS). On 2/18/25 at 1:09 PM, Staff J, Licensed Practical Nurse (LPN) stated she did not check wander guards and did not know how to check them at this facility. Staff J stated she did not complete an orientation checklist, she was shown the medication cart and allowed to ask questions. On 2/18/25 1:20 PM, the Administrator said that she expected the nurses to know how to check the wander guard. Stated that the facility had a checklist and she expected the facility nurses to orient them. She acknowledged That Staff J had not been at the facility since 2023 and she would have expected the nurse to complete an orientation checklist since it had been so long. On 2/19/25 at 7:43 AM, the Administrator said that they had just…

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 facility document review, staff interviews, and facility job description review the facility failed to employ a staff with specialized training in infection prevention and control. The facility reported a census of 25 residents. Findings include: Review of a facility document dated 12/24 titled, Job Description Manual/Infection Prevention (IP) Nurse position description revealed the Infection Preventionist must possess current, specialized training and certification in Infection Control (IC) in an approved course. On 2/19/25 at 9:05 AM the Assistant Director of Nursing (ADON) stated she was certificated in infection prevention. The ADON stated that she completed the IP course but was unable to find the document at the moment. On 2/19/25 at 9:18 AM the Interim Administrator stated the facility did not have a copy of the IP nurse certification. The Interim Administrator acknowledged the facility was unable to produce the certification for the IP nurse. The Interim stated the facility would expect the IP nurse would have appropriate certification for the position. Request for…

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 Electronic Health Record (EHR) review, and staff interviews the facility failed to develop and implement policies and procedures, to ensure the resident's medical record included documentation that the resident did or did not receive pneumococcal immunizations for 4 of 5 residents reviewed (Resident #6, #13, #17, and #20). The facility reported a census of 25 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #6 EHR revealed no document of consent or declination for the pneumococcal immunization and no documentation the resident ever received pneumococcal immunization. 2. The MDS dated [DATE] for Resident #13 documented a BIMS of 13 indicating no cognitive impairment. Review of Resident #13 EHR revealed no document of consent or declination for the pneumococcal immunization and no documentation the resident ever received pneumococcal immunization.…

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 Electronic Health Record (EHR) review, policy review, and staff interviews the facility failed to develop and implement policies and procedures, to ensure the resident's medical record included documentation that the residents were offered the immunization and did or did not receive the COVID-19 immunizations for 4 of 5 residents reviewed (Resident #3, #6, #13, and #17). The facility reported a census of 25 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview of Mental Status (BIMS) of 9 indicating moderate cognitive impairment. Review of Resident #3's EHR revealed no document of consent or declination for the COVID-19 immunization. 2. The MDS dated [DATE] for Resident #6 documented a BIMS of 15 indicating no cognitive impairment. Review of Resident #6's EHR revealed no document of consent or declination for the COVID-19 immunization. 3. The MDS dated [DATE] for Resident #13 documented a BIMS of 13 indicating no cognitive impairment.…

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 review, and staff interviews the facility failed to ensure that all Certified Nurse Aides (CNA's) had completed the required 12 hours of continuing education annually for 2 of 5 files reviewed. The facility reported a census of 25 residents. Findings include: A review of the personal files for CNA's revealed that two charts lacked evidence that they had completed 12 hours of annual training; Staff E, CNA, hired on 1/2/23, and Staff A, CNA hired on 12/27/23. On 2/19/25 at 7:43 AM the Administrator said that they have established an Inservice schedule with each session lasting an hour. She said that in the last month they had reviewed with the staff, the expectations of attending monthly in-services. On 2/20/25 at 8:28 AM the Administrator said they did not have a policy on CNA annual training requirements. According to the Facility Assessment updated on 2/2025, CNA's would have ongoing training, monitoring and supervision done by the charge nurse or nurse administration staff. An Annual In-Service Calendar showed the plan for monthly education that would…

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 observations, interviews, clinical record review, and facility policy the facility failed to provide dignity to 3 out of 16 residents (Resident #2, #1, #10). The facility failed to provide dignity to residents as demonstrated by a resident waiting over 45 minutes for toileting, not providing privacy with incontinence, and personal embarrassment of a resident due to incontinence. The facility reported a census of 25 residents. Findings Include: 1. The Minimum Data Set (MDS) for Resident #2, dated 1/5/25 identified a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognitive functioning. The document revealed the resident had no behaviors. The resident had diagnoses of cerebrovascular accent (CVA) with hemiplegia or hemiparesis (stroke with an affected extremity(ies)), depression, and adjustment disorder, unspecified. With toileting, transfers, and bed mobility the resident required total assistance from staff. The document revealed Resident #2 utilized a power wheelchair 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.

Based on staff interviews, personnel record reviw and policy review the facility failed to ensure background checks were completed before hire for 1 of 5 staff reviewed. The facility reported a census of 25 residents. Findings include: In a review of staff files it was discovered that Staff G, Director of Nursing (DON) was hired on 12/2/24. An Authorization for Release of Child and Dependent Adult Abuse Information signed on 11/29/24 by the Administrator at the time. The section of the document titled: Completed by the Central Abuse Registry, indicated that the person whose information was being requested was listed on the Child Abuse Registry (Staff G) as having abused a child. The file lacked documentation of any follow up inquiry into the details of why Staff G was listed on the Registry. On 2/19/25 at 12:12 PM, Staff M, Nurse Consultant, said that she traveled to several different facilities and she started coming to this facility to help with transitions in leadership, in October. She spent most of her time with education of staff and was at this facility a couple days a week.…

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 complete a Pre-admission Screening and Resident Review (PASARR) process for 2 of 2 residents (Resident #15, Resident #21) reviewed for PASARR. The facility failed to complete a new PASARR for a resident who was diagnosed with new mental disorder diagnoses since completion of the previous PASARR and failed to coordinate assessments with the PASARR program by incorporating the recommendations into a resident's assessment and Care Plan. The facility reported a census of 26 residents. Findings include: 1. Review of Resident #15's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS further revealed a diagnosis of Bipolar Disorder, Alcohol Induced Acute Pancreatitis without Necrosis or Infection, and Adjustment Disorder with Anxiety. The document indicated the resident received antidepressant and hypnotic medications. The MDS failed 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 clinical record reviews, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic medication use for 1 of 2 residents reviewed (Resident #15). The facility reported a census of 25 residents. Findings include: Review of Resident #15's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS further revealed a diagnosis of bipolar disorder, alcohol induced acute pancreatitis without necrosis or infection, and adjustment disorder with anxiety. The document indicated the resident received antidepressant and hypnotic medications. The Physician Orders for Resident #15 dated 2/4/25 identified the resident was prescribed: a.) Caplyta Oral Capsule 21 MG (Lumateperone Tosylate) Give 1 capsule by mouth one time a day for depression - Start Date 11/09/2024 2000 b.) Trazadone HCI Oral Tablet 100 mg/day at bedtime for depression - start date 9/11/24 and discontinued 2/11/25. The Physician…

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 facility document review and staff interview, the facility failed to submit 4 of 4 residents reviewed to the Iowa Department of Veteran Affairs (Resident #12, #18, #22, and #26). The facility reported a census of 25 residents. Findings include: A review of the admissions from 6/1/24 -2/17/25 revealed Resident #12 was admitted on [DATE] and remained in the facility. The facility failed to have the resident complete the Veteran's Questionnaire. A review of the admissions from 6/1/24 -2/17/25 revealed Resident #18 was admitted on [DATE] and discharged on 1/8/25. The facility failed to have the resident complete the Veteran's Questionnaire. A review of the admissions from 6/1/24 -2/17/25 revealed Resident #22 was admitted on [DATE] and remained in the facility. The resident Questionnaire for a VA benefit Eligibility dated 2/19/25 completed by the Interim Administrator indicated he was a veteran and served in the Army. The Iowa Department of Veterans Affairs Resident Eligibility form printed on 2/19/25…

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 observations, staff and resident interviews, clinical record review and facility document review the facility failed to ensure that they provided adequate nurse staffing to meet the needs for 3 of 4 residents reviewed. Residents #1, #3 and #4 indicated that many times there were only 2 staff on duty and they waiting a long time to get a response to their call lights. When the facility didn't have anyone else to work, Staff D, Licensed Practical Nurse (LPN) worked 23 consecutive hours and 49 hours in a three-day period. The facility reported a census of 24 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment, dated 10/29/24, Resident #1 was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) assessment, dated 10/30/24 at 8:41 AM, showed that Resident #1 had a score of 15 (cognitively intact). A document titled: Functional Abilities and Goals, dated 11/5/24 at 8:31 AM, showed that Resident #1 had lower extremity impairment on both sides. He was…

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 facility document review, and staff interviews the facility failed to ensure that a Registered Nurse (RN) was at the facility for 8 consecutive hours every day. In a 30-day timeframe, 4 days with no RN coverage. The facility reported a census of 24 residents. Findings include: In a review of the nursing schedule for the month of November 2024, it was discovered that there were no RN's scheduled on the 9th, 10th, 17th and 23rd. On 11/26/24 at 11:38 AM, the Director of Nursing (DON) said that she was a Registered Nurse and at the facility through the week and occasionally, on the weekends. She acknowledged that there was no RN coverage on November 9, 10, 17, or 23rd. She said that she would be talking to the Administrator on how they would handle RN coverage going forward. On 11/26/24 at 12:55 PM, Staff F, Nurse Scheduler, said that it had been very difficult to ensure they had RN coverage when they didn't have any on call staff and needed to rely on agency nurses. On 11/26/24 at 1:00 PM, the DON said…

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, interview and record review the facility failed to develop a care plan for 1 of 4 residents reviewed. Resident #1 was admitted to the facility on [DATE], as of 11/26/24 the clinical record lacked a care plan. The facility reported a census 24 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 was admitted to the facility on [DATE] from the hospital. A Brief Interview for Mental Status (BIMS) assessment, dated 10/30/24 at 8:41 AM, showed that Resident #1 had a score of 15 (cognitively intact). A document titled: Functional Abilities and Goals, dated 11/5/24 at 8:31 AM, showed that Resident #1 had lower extremity impairment on both sides. He was totally dependent on staff for toileting hygiene, lower body dressing, and showering. He required substantial assistance with rolling over and sit to lying. Sit to stand, bed to chair transfers, toilet transfers and walking were not attempted in the 3 day look back period due to medical conditions…

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, resident interview, staff interviews and clinical record review the facility failed to ensure they had the proper equipment and services to meet the needs of residents before admission for 1 of 1 residents reviewed. Resident #1 sustained a knee injury that required therapy services and the facility agreed to accept the resident before considering his bariatric equipment needs. The facility reported a census of 24 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 was admitted to the facility on [DATE] from the hospital. A Brief Interview for Mental Status (BIMS) assessment, dated 10/30/24 at 8:41 AM, showed that Resident #1 had a score of 15 (cognitively intact). The following documentation was found in the Progress Notes: 1) On 10/29/24 at 3:29 PM, the resident arrived via ambulance with a knee injury. He had bilateral lower extremity swelling and he was able to stand with a walker and transfer to bed. 2) On 10/30/24 at 4:45 PM, the…

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 clinical record review, resident and staff interviews, and facility policy review the facility failed to protect 1 of 3 residents (Resident #1) from psychosocial harm during and after the investigation of an allegation of abuse. The facility reported a census of 26 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 6/24/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairments. Resident #1 had an admission date of 6/19/24. The MDS documented she did not display any physical, verbal, or other behavioral symptoms during the review period. The MDS documented she was frequently incontinent of urine and was always incontinent of bowel. The MDS listed the following diagnoses for Resident #1: acute cystitis with hematuria, anemia, neurogenic bladder, multidrug resistant organism, septicemia, urinary tract infection (UTI), cerebral palsy, anxiety, depression, psychotic disorder (other than schizophrenia), post-traumatic stress…

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 document review, electronic health records (EHR), observation, staff interviews, and policy review the facility failed to follow physician orders (Resident #2), failed to direct the implementation of physician orders and failed to administer medications as ordered by not transcribing orders for 2 of 2 residents (Resident #2 and #4) reviewed. The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of the EHR for Resident #2, the Medication Administration Records (MAR) for the month of June 2024 documented an order for Lidocaine external cream 5% applied to right lower extremity lateral calf topically daily 30 minutes prior to wound care. On 6/25/24 at 6:13 AM an observation revealed Staff E, Registered Nurse (RN) / Assistant Director of Nursing (ADON) obtained supplies for wound treatment, completed hand…

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 observations, vendor interviews, staff interviews, and facility document review the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident by maintaining a status of non-payment with several local vendors. The facility reported a census of 28 residents. Findings include: On 6/24/24 at 11:00 AM Staff A, Certified Nursing Assistant (CNA) stated the garbage has piled up for longer than a week. Staff A stated the excessive garbage is to the point it has to be piled outside the dumpster and it has happened twice now since she has worked at the facility. Staff A stated the garbage was not picked up for a little over 2 weeks both times. Staff A stated the Administrator told her when concern was expressed that the corporation did not pay the garbage bill. Staff A stated the facility had an unpaid bill to the transportation provider as well. Staff A stated residents had missed appointments…

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, facility record review, policy review, and staff interviews the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 2 of 3 residents (Resident #1, and #23) reviewed. The facility reported a census of 28 residents. Findings include: 1. Review of Resident #1's Electronic Health Record (EHR) revealed Resident #1 in the hospital from [DATE] through 7/31/23 and again in the hospital from [DATE] through 8/10/23. Further review of the EHR page titled, Clinical Census, confirmed the resident in the hospital on these dates. 2. Review of Resident #23's EHR revealed Resident #23 in the hospital from [DATE] through 2/1/23. Further review of the EHR page titled, Clinical Census, confirmed the resident in the hospital on this date. Review of a facility provided document titled, Notice of Transfer Form to Long-Term Care Ombudsman with dates on it from August 2023 to September 2023 revealed Resident #1 not on the document. During an interview 3/20/24 at 10:40…

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 obtain bed hold notifications for 2 of 3 residents (Residents #1, #23) reviewed. The facility reported a census of 28 residents. Findings include: 1. Review of Resident #1's Electronic Health Record (EHR) revealed Resident #1 was in the hospital from [DATE] through 7/31/23 and again in the hospital from [DATE] through 8/10/23. Further review of the EHR page titled, Clinical Census, confirmed the resident in the hospital on these dates. 2. Review of Resident #23's EHR revealed that Resident #23 in the hospital from [DATE] through 2/1/23. Further review of the EHR page titled, Clinical Census, confirmed the resident in the hospital on this date. Review of bed hold notification for Residents #1, and #23 revealed no bed hold forms to review for the dates of hospitalization. During an interview 3/19/24 at 2:00 PM with Staff A, Social Services, revealed she did not have the bed hold forms for the dates Resident #1 and #23 went…

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 interview, and policy review, the facility failed to fully review and revise the comprehensive care plan for 1 of 1 resident reviewed (#18). The facility reported a census of 28. Findings include: The quarterly Minimum Data Set (MDS) for Resident #18 dated 7/10/23 included diagnoses of cancer, congestive heart failure, pulmonary edema (fluid in the lungs), hypertension, and cellulitis of the bilateral lower legs. It indicated the resident received an anticoagulant medication within the seven (7) day look-back period. It also identified a Brief Interview of Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. The quarterly MDS dated [DATE] indicated the resident routinely received the anticoagulant medication. A review of physician medication orders revealed the anticoagulant medication prescribed on 5/02/23 for a history of an acute embolism and thrombosis of a deep vein in the right lower extremity (blood clot in the right lower leg deep vein). The…

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 facility document review and staff interview, the faciltiy failed to review and update their facility assessment, as necessary, and at least annually. The facility reported a census of 32 residents. Findings include: Review of the Facility Assessment reviewed a date of assessment or update as 1/28/22. In an interview on 8/1/23 at 10:18 AM, the Chief Nurse Officer (CNO) reported that she was aware that the facility assessment as last completed in 2022 and that she had been working with the facility's management to update the facility assessment so that it follows Center for Medicare and Medicaid (CMS) regulation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, the facility failed to investigate alleged sexual abuse between 2 of 4 residents reviewed (Resident #4 and #5). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging…

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 complete a recapitulation of stay, a final summary of the resident's status, that included the course of treatment for blood sugar checks, the foley catheter and wound care for 1 of 1 residents reviewed (Residents #1) for discharge from the facility. The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) dated [DATE] listed an admission date of 3/3/23. The MDS identified a Brief Interview of Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS included diagnoses of medically complex conditions of peripheral vascular disease, diabetes mellitus, psychosis and above the knee amputee of the right and left leg. The MDS indicated Resident #1 had an inserted urinary catheter, and required insulin injections. The Fax (facsimile) Cover Sheet dated 3/12/23 for Resident #1 signed by a physician included an order to continue with foam dressing changes for the…

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, facility policy review, and staff interview the facility failed to maintain accurate medical records for 1 out of 13 residents reviewed (Resident #1). The facility reported a census of 32 residents. Findings Included: Resident #1's Minimum Data Set (MDS) dated [DATE] listed an admission date of 3/3/23. The MDS identified a Brief Interview of Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS included diagnoses of medically complex conditions of peripheral vascular disease, diabetes mellitus, psychosis and above the knee amputee of the right and left leg. The MDS indicated Resident #1 required extensive assistance of two plus persons for bed mobility, total dependency for transfers and used a wheelchair for a mobile device. The MDS documented the resident did not have any skin conditions. The Progress Note dated 3/12/23 at 9:51 AM for Resident #1 identified multiple small opened skin areas on the left and right buttock, and a large…

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.