The Bridges at Ankeny

Based on observation, clinical record review, resident and staff interview and facility policy review, the facility failed to provide proper perineal care for 1 of 3 residents reviewed. (Res #4 ) The facility identified a census of 84 residents. Findings include: According to a Minimum Data Set (MDS) assessment dated 5.8.25 Resident #4 had diagnosis that included Renal Insufficiency, Anxiety, Chronic Respiratory Failure, muscle weakness and required assistance with personal cares. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (moderately impaired cognitive skills) and required substantial/maximum assistance with toileting hygiene. A Care Plan addressed a Problem area and Interventions as stated and dated below: a. Self-care deficit as evidence by required assistance with activities of daily living (ADL's), impaired balance during transitions and required assistance with ambulation. (revised 4.22.25) 1. Assistance of one (1) with a front wheeled walker (FWW) and provision of perineal care with every incontinence episode 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 observation, clinical record review, document review, resident, family, and staff interviews, the facility failed to provide sufficient staff to ensure call lights were answered within a reasonable amount of time (within 15 minutes) to provide needed care and supervision to residents. Family members and residents reported having to wait thirty to sixty minutes for the call light to be answered numerous times during the week. Observation of the call light system revealed the call lights were answered between one to sixty four minutes. The facility reported a census of 83 residents. Findings include: Observations revealed the following: On 2/19/25 at 7:37 AM, the Palatium Care Monitor located at the nurse's station revealed call lights had been on for the following rooms and the amount of time the call light had been on at that time: room [ROOM NUMBER] - 21 minutes room [ROOM NUMBER] - 32 minutes room [ROOM NUMBER] - 24 minutes room [ROOM NUMBER] - 27 minutes On 2/19/25 at 7:45 AM, the Palatium Care…

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, family and staff interview, the facility failed to involve the resident and/or resident's representative in care conferences and ensure care conferences held at least quarterly for one of three residents reviewed for care conferences (Resident #63). The facility reported a census of 83 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had diagnoses of cerebrovascular accident (CVA)(stroke), cancer, and dementia. The MDS revealed the resident admitted to the facility on [DATE]. The MDS indicated the resident had severely impaired decision making skills. The MDS indicated the resident's preferences for the family or significant other to be involved in care discussions The Progress Notes dated 8/28/24 at 10:11 AM revealed a Care Conference was held on 8/28/24. In an interview on 2/17/25 at 1:29 PM, a family member reported only two care conferences held in the past year, and only one care conference held since the new company took…

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 facility policy review, the facility failed to follow accepted professional standards and practices regarding medication being left in the open. The facility reported a census of 83. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #20, dated 02/06/2025, documented the resident was rarely or never understood. It documented the following relevant diagnoses: Hypertension (high blood pressure), Renal Insufficiency (kidney failure), Hyperlipidemia (high cholesterol), Alzheimer's disease, Non-Alzheimer's dementia, Malnutrition, Anxiety disorder, Depression, and hypokalemia (low potassium). The Care Plan for Resident #20, last revised on 12/03/2024, instructed staff members to administer medication as ordered and to monitor the resident for side effects and effectiveness. The Medication Administration Record (MAR) documented the resident was to receive Potassium Chloride ER 20 milliequivalents, once a day for low potassium.…

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, family interview and policy review the facility failed to provide oral hygiene cares as directed in the care plan for 3 of 3 residents reviewed for oral cares (Resident # 63 and #25). The facility reported a census of 83 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had diagnoses of cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis on one side of the body), cancer, and non-Alzheimer's dementia. The MDS revealed the resident had impaired memory and severely impaired decision-making skills. The MDS documented the resident dependent for oral hygiene. The MDS assessment under Section L left blank, indicated the resident did not have broken or loosely fitting dentures or mouth pain. The Care Plan revised 2/27/24 revealed the resident had a history of CVA with left sided hemiplegia and required assistance with Activities of Daily Living (ADL's). The resident had her own teeth. The Care Plan directed staff to encourage 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 record review, observations, and family and staff interviews, and policy review the facility failed to carry out therapy recommendations and provide restorative exercises for 3 of 4 residents reviewed for restorative services and/or limited range of motion (Resident #36, #54 and #63). The facility reported a census of 83 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had diagnoses of cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis on one side of the body), Alzheimer's Disease, dementia, and weakness. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS documented Physical Therapy (PT) and Occupational Therapy (OT) services started on 4/4/24 The MDS indicated the resident had impaired Range of Motion (ROM) to the upper and lower extremities on one side. The resident required partial to moderate assistance for eating, substantial 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 observations, record review, staff interview, and policy review the facility staff failed to ensure a resident's bed was placed in a low position to ensure the resident's safety for one of five residents reviewed for transfers (Resident #12). The facility reported a census of 83 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated revealed 12/27/24 revealed Resident #12 had diagnoses of dementia, osteoporosis, and anxiety disorder. The MDS recorded the resident had a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. The MDS indicated the resident dependent on staff for bed mobility and transfers. The Care Plan revised on 12/23/24 revealed the resident had impaired cognitive function and impaired thought processes as evidenced by short and long term memory deficit and impaired decision-making related to diagnosis of dementia. The resident also had a risk of falls related to poor safety awareness, functional impairment, and use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and policy review the facility failed to provide complete incontinence care for one of four residents observed (Resident #27) for incontinence care. The facility reported a census of 83 residents. Findings include: The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had diagnoses of end stage renal disease, obstructive uropathy (a urinary tract disorder), and diabetes. The MDS indicated the resident had an indwelling catheter and had dependence on staff for toileting. The Care Plan revised 6/12/24 revealed the resident had a suprapubic catheter. The Care Plan directed staff to provide catheter care per facility policy. On 2/18/25 at 2:45 PM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, washed their hands and donned a pair of gloves. Staff A and Staff B transferred Resident #27 from the broda chair to the bed using a mechanical lift. The cushion in the Broda chair was visibly wet. Staff A and Staff B…

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, resident and staff interview, and facility document review, the facility records failed to maintain complete and accurate documentation for 1 of 22 residents reviewed (Resident # 23). The facility reported a census of 83. Findings Include: The Annual minimum data set (MDS) for Resident #23, dated 02/06/2025, documented her brief interview for mental status score (BIMS) as 14, indicating intact cognition. In an interview on 02/18/2025 at 01:51 PM with Resident #23, she reported that on 02/12/2025 she was ambulating independently in her room when she slipped and fell over her four wheeled walker. She reported she was assisted to her feet by the Certified Nurses' Assistants (CNAs) and assessed after her fall by one of the nurses. She did not initially report pain, but noted that by 02/15/2025 she was in so much pain that her prescribed pain medication no longer helped. At this point she was convinced to go to the emergency room for assessment. She reports that after assessment in…

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, observations, staff interview, and policy review the facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP's) when cares provided for one of six resident sampled on EBP's (Resident #27). The facility reported a census of 83 residents. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had diagnoses of end stage renal disease, obstructive uropathy, and diabetes. The MDS indicated the resident had an indwelling catheter. The MDS revealed the resident had dependence on staff for toileting. The Care Plan revised 6/12/24 revealed the resident had a suprapubic catheter. The resident required EBP's related to presence of indwelling suprapubic catheter. The Care Plan directed staff to implement and adhere to EBP's during completion of high contact activities, and hand hygiene prior to and after cares. Observations revealed the following: a. On 2/17/25 at 9:49 AM, an EBP sign hung on the wall in the resident's room and a 3-drawer bin sat on the floor by…

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, call light event report, resident, family and staff interviews, and policy review, the facility failed to answer call lights in a timely manner within 15 minutes and adequately assess and ensure sufficient staff to meet the residents' needs for 6 of 6 nursing units. The facility reported a census of 87 resident. Findings include: Observations revealed the Palatium Care Alert monitor located on the counter at the nurse's station revealed the following: a. On 9/17/24 at 12:28 PM, room [ROOM NUMBER]'s call light had been on for 20 minutes. b. On 9/17/24 at 12:49 PM, room [ROOM NUMBER]'s call light had been on for 32 minutes, room [ROOM NUMBER]'s call light had been on 18 minutes, and room [ROOM NUMBER]'s call light had been on for 21 minutes. c. On 9/18/24 at 3:31 PM, room [ROOM NUMBER]'s call light had been on for 33 minutes. The Detailed Event Report dated 9/11/24 - 9/16/24 revealed call light response times greater than 15 minutes in a 24-hour period on the following dates: 9/11/24 -50…

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 assessment review, and resident, family, and staff interviews, the facility failed to adequately evaluate their resident population and identify required resources and staffing levels needed to provide the necessary care and services needed for current residents. The facility reported a census of 87 residents. Findings include: A review of the Facility Assessment updated on 3/2024 revealed the facility assessment updated as indicated and whenever a significant change including facility capacity or the services provided. A facility assessment utilized to determine the resources needed to care for the resident population served during day-to-day operations as well as during emergency situations. The facility's assessment included the following: a. Part 1 - Resident Profile - Average census: 45-59 - Average Skilled Care residents per day: 15-25 - Average long-term care residents per day: 60-75 The facility assessment included the acuity of residents and the ADL (activities of daily living) assistance required for residents on the 300-400 and 500-600 halls. 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, observations, staff interview, and policy review the facility failed to provide toileting assistance and care for a resident in an environment that maintained or enhanced dignity for one of ten residents sampled (Residents #7). The facility reported a census of 87 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had diagnoses of liver cirrhosis and cancer. The MDS indicated the resident had dependence on staff for transfers and toileting hygiene. The MDS documented the resident had frequent bowel incontinence. The Care Plan revised 7/18/24 revealed the resident had bowel incontinence and at risk for impaired skin and infection in the periarea. The resident also required assistance with activities of daily living (ADL's) due to incontinence. The Care Plan directed staff to provide assistance of two for toileting and keep the call light within reach for the resident to notify nursing he needed to use the toilet or had an…

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 and staff interview, the facility failed to maintain a safe, clean, and homelike environment due to food being left on the floor of the dining hall for multiple days without having been cleaned. The facility reported a census of 87. Findings include: A direct observation on 09/16/24 at 12:19 PM of the memory care unit dining hall revealed eggs with a dried appearance on the floor and the tables of the dining hall, a garbage can overflowing with trash from previous dining services, as well as smears of jelly and and unidentifiable substance on the floors. These were not cleaned before seating residents in the dining hall and serving them lunch. A second direct observation of the memory care unit dining hall on 09/16/24 at 05:03 PM revealed the eggs and other food items remained on the floor from an earlier meal. The garbage had not been emptied. A third direct observation on 09/17/24 at 12:44 PM revealed the food items still on the floor, easily identified as now dry egg, smears of jelly, and unidentifiable substances remained in the same locations as…

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, family and staff interviews, and facility document review, the facility failed to follow Care Plans for 1 of 18 residents observed (Resident #3). The facility reported a census of 87. Findings include: The Quarterly Minimum Data Sample (MDS) for Resident #3, dated 07/19/24, documented relevant diagnoses of cerebral infarction (stroke), anxiety disorder, and non-Alzheimer's Dementia. It further documented a history of falls, and a daily behavior of scratching oneself. The MDS documented the resident had severely impaired cognitive skills for daily decision making. The Care plan, last revised on 08/07/24, documented the need for Geri-Sleeves (protective sleeves for the arms or legs that are designed to protect the resident's skin against skin tears, bruising, and abrasions) as well as fall mats to be placed by the bed while the resident is laying in bed to prevent injury in the event of a fall. The Medication Administration Record (MAR) dated from 09/01/24 to 09/18/24 directed staff as follows; (start date 1/10/24) Geri-Sleeves to both upper extremities 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 direct observation, clinical record review, and family and staff interviews, the facility failed to administer oxygen and other respiratory treatments in accordance with physician orders and resident Care Plans for 1 of 13 residents on oxygen or respiratory therapies (Resident#3). The facility reported a census of 87. Findings include: The Quarterly Minimum Data Sample (MDS) for Resident #3, dated 07/19/24, documented relevant diagnoses of cerebral infarction (stroke), anxiety disorder, and non-Alzheimer's Dementia, congestive heart failure, respiratory failure, cerebral vascular event (stroke), chronic obstructive pulmonary disease (COPD). The MDS documented the resident had experienced shortness of breath when laying flat, and was on oxygen therapy. The Care plan, last revised on 08/07/24, documented the need for continuous oxygen via a nasal cannula. It did not specify what oxygen saturation was within a normal or ideal range for Resident #3. Review of the electronic health record (EHR) documentation…

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, staff interview, and facility document review, the facility failed to serve each resident with a nourishing, well-balanced diet that takes into consideration the preferences of the resident for 1 of 18 residents assessed (Resident #6). The facility reported a census of 87. Findings include: A direct observation of the meal service on 09/17/24 at 12:44 PM revealed a slow, chaotic service in which lunch did not begin being served until 01:13 PM. During the service kitchen and nursing staff were seen assisting residents in the dining room, but no assistance was provided to residents who chose to eat in their rooms or were otherwise confined to their beds. Meal service in the dining hall ended at 01:53 PM, at which point the remaining food, including two resident meals, was removed from the floor. A direct observation on 09/17/24 from 2:00 PM until 02:50 PM showed that after lunch service in the dining hall ended, the residents who had not dined with their peers in the dining hall were…

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, and policy review the facility staff failed to wear gloves and follow Enhanced Barrier Precautions (EBP) and infection control practices for 1 of 10 residents reviewed (Resident #7). The facility reported a census of 87 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had diagnoses of liver cirrhosis, cancer, chronic kidney disease, and neurogenic bladder. The MDS documented the resident had a catheter. The Care Plan revised 9/10/24 revealed Resident #7 had a catheter and on EBP. The resident also had a history of urinary tract infection and sepsis (a life-threatening complication of infection). The Care Plan directed staff to use enhanced barrier precautions during completion of high contact activities. During observation on 9/16/24 at 1:50 PM, Staff F, Certified Nursing Assistant (CNA), donned a gown and a pair of gloves. Staff F obtained supplies and drained the urine contents from…

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 4. The Minimum Data Set (MDS) for Resident #9, dated 3/15/24, documents the resident is always incontinent of urine and frequently incontinent of bowel. The MDS further documents diagnoses to include debility, cardiorespiratory conditions, coronary artery disease, heart failure and renal insufficiency. The Care Plan for Resident #9, with an initiation date of 4/2/24, documents under the problem section the resident is incontinent of bowel and bladder and instructs staff under the interventions section to clean peri-area with each incontinence episode. During an observation 4/2/24 at 2:34 PM, Staff J, Certified Nursing Assistant (CNA), began to perform peri care to Resident #9 after an episode of bowel incontinence, with Staff K, Assistant Director of Nursing (ADON), present. Staff J did not wash her hands prior to placing gloves on her hands to begin the peri care, and with a wipe cleaned back to front for the first swipe of peri care. The remaining wipes were performed front to back. The mechanical sling 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 clinical record review, staff interview, and policy review, the facility failed to provide discharge and medical information to the receiving health care institution at the time of discharge for one of four residents reviewed who transferred to the hospital (Resident #76). The facility reported a census of 82 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 readmitted to the facility from the hospital on 2/11/2024. Review of the facility's electronic medical record Census List revealed Resident #76 had transferred to the hospital on 2/11/2024, and re-admitted to the facility on [DATE]. The Progress Note dated 2/11/2024 at 05:00 AM., documented that Resident #76 transported to hospital for placement of G-tube. The clinical record lacked documentation of information sent when the resident transferred to the hospital on 2/11/2024. During an interview 04/03/2024 at 4:17 PM, the Director of Nursing (DON) reported no transfer form completed…

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 notify the Long Term Care (LTC) Ombudsman of a resident transfer as required for 1 of 4 residents reviewed who were transferred from the facility (Residents #76). The facility reported a census of 82 residents. Findings include: The Quarterly7 MDS (Minimum Data Set) assessment dated [DATE] and the Census List for Resident #76 documented that the resident had transferred from the facility on 2/11/2024, and reentered the facility on 2/11/2024. The clinical record lacked documentation of notification to the LTC Ombudsman that Resident #76 had transferred to the hospital as required by federal regulation. During an interview 04/03/2024 at 2:47 PM the Administrator and Administrator's Assistant stated the facility did not report to the Ombudsman whenever residents had an Emergency Department (ED) visit In an email on 04/03/2024 at 01:47 PM, the Administrator wrote no ombudsman policy, they followed the state/federal regulations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to develop and update the comprehensive Care Plan with Preadmission Screening and Resident Review (PASRR) Level II service recommendations for one of one resident reviewed who had a PASRR Level II determination (Residents #19). The facility reported a census of 82 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 admitted to the facility on [DATE] and had diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder. The Care Plan revised 2/15/24 revealed the resident had a diagnoses of bipolar disease and at risk for extreme mood swings, agitation, and paranoia. The resident had a PASRR completed and a Level II determined. The Care Plan directed staff to follow any specialized services and specialized rehabilitation services recommended. The Care Plan lacked the PASRR recommended services. The PASRR dated 1/26/24 revealed a Level II…

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, family and staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 18 residents reviewed for care plans (Resident #48, #55 and #76). The facility reported a census of 82 residents. Findings include: 1. The Entry Minimum Data Set (MDS) for Resident #48, with a date of 12/27/23, documents the resident was admitted to the care facility on 12/27/23 from a skilled nursing facility. Review of the electronic health record (EHR) for Resident #48 reveals a progress note on 12/27/23, titled admission summary, documenting the resident admitted to the nursing facility with lower dentures. During an interview 4/2/24 at 10:02 AM, a family member advised there have been times while visiting Resident #48 the resident did not have her dentures in, the resident has a partial lower plate. During an observation 4/2/24 at 12:55 PM, Resident #48 was not wearing her dentures. This was during lunch service. The Care Plan 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 record review, staff interview and policy review, the facility failed to review and revise a resident's Care Plan (Resident #26) to meet the resident's needs for catheter care for 1 of 18 residents reviewed for comprehensive care plans. The facility reported a census of 82 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #26 documented the resident had a Brief Interview for Mental Status (BIMS) of 8, which indicated moderately impaired cognition. The MDS further documented diagnoses to include medically complex conditions, cancer, heart failure, cirrhosis, septicemia (blood poisoning by bacteria) and urinary tract infection (in the last 30 days). The MDS documented the resident admission date of 2/21/24 from a short-term general hospital. Progress Note BAA-SNF/Covid assessment dated [DATE] at 7:00 PM documented as follows; incontinent of bowel and bladder, pull ups, briefs, urinal used every two hours, and as needed. No urinary catheter noted. BAA-Order Note…

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 instructions, and policy review, the facility failed to assure a medication error rate of less than 5%. During observation of medication administration, the facility had 2 errors out of 32 opportunities for error resulting in an error rate of 6.25% (Residents #11). The facility identified a census of 82 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had diagnoses of diabetes. The MDS documented the resident took insulin during the 7-day lookback period. The Medication Administration Record (MAR) for Resident #11 listed Glargine insulin 30 units subcutaneously (SQ) and Humalog (lispro) insulin 2 units SQ administered by Staff B, Licensed Practical Nurse (LPN) on 4/2/24 during the AM for diabetes. During observation on 4/2/24 at 8:20 AM, Staff B, Licensed Practical Nurse (LPN), prepared to administer insulin for Resident #11. Staff B reported Resident #11's blood sugar…

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 two of two insulin flexpens properly to ensure the proper amount of insulin administered during medication pass (Resident #11). The facility reported a census of 82 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had diagnoses of diabetes. The MDS documented the resident took insulin during the 7-day lookback period. The Medication Administration Record (MAR) for Resident #11 listed Glargine insulin 30 units subcutaneously (SQ) and Humalog insulin 2 units SQ administered on 4/2/24 during the AM for diabetes by Staff B, Licensed Practical Nurse (LPN). During observation on 4/2/24 at 8:20 AM, Staff B, LPN, prepared to administer insulin for Resident #11. Staff B reported Resident #11's blood sugar 249. Staff B dialed the Lantus flexpen to 30 (units), and the Humalog flexpen to 2 (units). Staff B administered the Lantus…

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, provider interview, clinical record review, and facility policy review the facility failed to provide assessment and intervention to identify pressure ulcer development for 1 of 3 residents reviewed (Resident #4). Resident #4 developed a wound on her coccyx and the nurse who applied the treatment failed to assess the area and identify the pressure ulcer (PU). The facility failed to do a nursing assessment when applying the treatment to the area. The wound on Resident #4's coccyx (tailbone) was determined to be a Stage 2 Pressure Ulcer. The facility's nurses were not staging pressure ulcers and there was confusion regarding who was to identify the areas as pressure and then stage areas if they were pressure. The facility reported a census of 96 residents. Findings include: The MDS (Minimum Data Set) 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…

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 staff interviews, observations, clinical record review, and facility policy review the facility failed to provide perineal (peri) care (groin and buttocks care) using accepted infection control practices for 1 out of 2 residents reviewed (Resident #4). An observation revealed that a Certified Nurse Aide provided peri care to Resident #4 without removing gloves between clean and dirty sites and used the same gloves to apply a cream to an open area on Resident #4's coccyx (tailbone). The facility reported a census of 96 residents. Findings include: A Minimum Data Set, dated [DATE], documented diagnoses for Resident #4 to include cerebral infarction, Stage 2 pressure ulcer of the sacral region, and non-Alzheimer's dementia. The Brief Interview for Mental Status for Resident #4 documented a score of 5 out of 15, which indicated severe cognitive impairment. The MDS documented the resident dependent on staff for transfers, required maximal assistance for turning from side to side and dependent on staff 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.