Bettendorf Health Care Center

Based on observations, clinical record review, and staff interviews, the facility failed to ensure pureed meat was reheated to 165 degrees for fifteen seconds when held for hot service after the temperature of the pureed meat dropped below 135 degrees Fahrenheit. The facility reported a census of 66 residents. Findings include: During an observation on 9/9/25 at 10:43 AM, Staff A, Dietary [NAME] prepared pureed meat for the lunch service. The turkey slices temped at 181 degrees. After the Staff A finished with her preparation of the puree meat, Staff A placed the prepared meat onto the steam table and did not take the temperatures of the meat prior to placing on the steam table. The Facility Spring/Summer 2025 menu revealed the following menu for Tuesday Week 3: Herbed turkey, baked potato, sour cream, sugar snap peas. During an observation on 9/9/25 at 11:32 AM, Staff A took the temperatures of the foods on the steam table prior to lunch service. The pureed turkey temped at 131.2 degrees. During an observation 9/9/25 at 11:45 AM, Staff A plated 3 pureed meals first. During 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 observation, record review, staff interviews, and the facility policy, the facility failed to clean the ceiling vents and oven hood and maintain the dishwasher sanitizer at the appropriate sanitizing level. The facility reported a census of 66 residents. Findings include: During the initial tour of the kitchen on 9/8/25 at 9:45 AM, the low temperature dishwasher tested for the sanitizer level. The strip tested and the color of the strip was gray and did not rise to the level 25 PPM (parts per million). The Dish machine PH log for September 2025 revealed initial [Initials redacted] on the 8th on the breakfast and lunch times with the number 150 next to the initials. During the initial tour of the kitchen on 9/8/25 at 9:45 AM, observation revealed the ceiling vents had thick dust on and around them above the steam table, and the hood above the oven and stove covered with dust and grime. During an interview on 9/8/25 at 10:07 AM, the Dietary Supervisor informed the dishwasher did not reach the appropriate PPM level. The Dietary Supervisor went and got the Maintenance…

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 and resident interviews, and facility policy review the facility failed to ensure residents remained free from verbal abuse, mental abuse, and neglect by facility staff for three of five residents reviewed for staff treatment (Resident #6, Resident#28, Resident #34). The facility reported a census of 66 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident#34 dated 6/26/25 listed diagnoses of cerebral palsy, cancer and neurogenic bladder. The Brief Interview for Mental States (BIMS) assessment reflected a score of 15 out of 15, which indicated intact cognition. The MDS revealed Resident #34 was always incontinent of bowel and bladder. Review of documentation dated 6/30/25 provided as part of a Facility Reported Incident regarding Resident #34 revealed, On 6/30/2025, Social Services was given a grievance form from [Name Redacted], Activity Director regarding resident [Resident #34]. Resident reported to Activity Aide that on second…

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, clinical record review, staff interviews and facility policy review the facility failed to provide incontinence care for two out of two residents reviewed (Resident #2 and Resident #20). The facility reported a census of 66 residents.Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 listed diagnoses of cerebrovascular accident (CVA),anxiety, and depression. The Brief Interview for Mental Status (BIMS) exam revealed a score of 14 out of 15, which indicated intact cognition. The MDS reflected Resident #2 was always incontinent of bowel and bladder. The Care Plan for Resident #2 initiated 2/9/22, revised 3/1/22, revealed, ADL (activities of daily living) self-care performance deficit Impaired balance, Limited Mobility, stroke. The Intervention dated 12/12/24 directed utilize check and change to manage incontinency. The Intervention dated 12/11/24 directed assist of 1 staff for personal hygiene. On 9/10/25 at 1:09 PM, Resident #2 laid in her bed, 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 observation, record review and staff interview the facility failed to utilize proper technique when dispensing oral medications to prevent spread of infections. The facility also failed to maintain a catheter bag off the ground to prevent infections for 1 of 2 residents reviewed for catheters (Resident #3). The facility reported a census of 66 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. It further indicated diagnoses including: atrial fibrillation (irregular heart beat), heart failure, urinary tract infection and chronic obstructive pulmonary disease. Per the assessment, the resident had an indwelling catheter. Review of the Order Summary Report with active orders as of 9/11/25 revealed an order for foley catheter to be changed every 30 days and as needed.The Care Plan for Resident #3, date initiated 7/7/25, indicated the resident needed…

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 employee file review, staff interviews, and facility policy review the facility failed to ensure a staff member completed the required Dependent Adult Abuse training withing six months of hire for one of eight staff reviewed (Staff S, Certified Nurse Aide). The facility reported a census of 66 residents.Findings include:Review of Staff S, Certified Nurse Aide (CNA)'s employee file listed she started on 2/27/25. The file failed to include Dependent Adult Abuse (DAA) certificate of training. The facility provided a document that reflected Staff S started on 2/20/25.The Time Card Report dated 9/10/25 revealed Staff S worked 7.75 hours that day.On 9/11/2025 at 9:59 AM, Human Resource Specialist reported new staff were required to complete the DAA training within 6 months of hire.On 9/11/25 at 10:15 AM, the Administrator reported Staff S attempted to complete the training and the system shut down on her. The Administrator confirmed Staff S failed to get the DAA training finished. The facility provided the policy titled Abuse, Neglect and Exploitation dated 4/29/25, directed…

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 resident and staff interviews, the facility failed to provide resident baths/showers twice weekly or as directed by resident preference for 4 of 5 residents (Resident's #2, #3, #4 and #5) reviewed in the sample. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. The MDS diagnoses listed included morbid obesity, depression, and wound infection. The MDS indicated Resident #2 required substantial staff support for bathing. The Care Plan, initiated on 7/10/23, included a Focus area to address ADL (activity of daily living, meaning showers, toothbrushing, etc.) self-care performance deficit Impaired balance, Limited Mobility. The Focus area included I may refuse baths at times. Please offer me a bed bath if I refuse a bath. Interventions,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to maintain 3 of 3 Shower Rooms in a functional and sanitary manner. The facility reported a census of 66 residents. Findings include: Observations on 1/12/25 revealed: At 2:12 p.m., the East Hall Shower Room with tiled shower stall that measured approximately 6 feet long by 4 feet wide, with 2 inch square tiles on the floor. Four floor tiles were missing in the shape of a square near the entrance to the stall, 8 floor tiles were missing by the drain in the shape of an L, and 2 floor tiles were missing in a rectangular shape at the rear of the shower stall. The grout between the floor tiles appeared dirty, a dark gray color, and the grout along the floor/wall junction of the left and rear walls with a thick black residue. At 3:03 p.m., the [NAME] Hall Shower Room with tiled shower stall that measured approximately 6 feet long by 4 feet wide, with 2 inch square tiles on the floor that had a dark gray colored build up of residue on 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 observation, clinical record review, resident and staff interviews, the facility failed to answer call lights within 15 minutes, with an observation of a staff response time of 32 minutes. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. The MDS diagnoses listed included morbid obesity, depression, and wound infection. The MDS indicated Resident #2 required substantial staff to change positions in bed, transfer to and from bed and chair, dressing toileting and bathing. During an interview on 1/23/25 at 10:40 a.m., Resident #2 stated he used his call light at least 3 or 4 times a day, and staff response times were usually 45 minutes or longer, it didn't matter what time of day or what day of the week. 2. The Daily Assignment Schedule for the Day Shift on 1/14/25 revealed Staff G, Certified…

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, staff interview and clinical record review the facility failed to provide adequate nail care for 1 out of 3 residents reviewed for activities of daily living (Resident # 51). The facility reported a census of 61 residents. Findings include: The Minimum Data Sheet (MDS) dated [DATE] for resident #51 documented the presence of short and long-term memory impairment. The MDS revealed Resident #51 moderately impaired decision making. The MDS indicated the resident required substantial to maximum staff assistance for bathing and hygiene. It documented diagnoses including non-Alzheimer's dementia and anxiety disorder. The Care Plan, Intervention, dated 6/21/24, directed staff to offer bathing/showering twice weekly and as necessary. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an observation on 08/12/24 at 11:27 AM Resident #51 sitting in wheelchair, toenails on both feet noted long, thick, and yellow in color curled over the top 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 observation, clinical record review, and staff interview the facility failed to follow a physician order to ensure a resident ate meals in a safe manner for 1 of 1 residents reviewed (Resident #38). The facility reported a census of 61. Findings include: The Minimum Data Set (MDS) assessment, dated 6/18/24, revealed Resident #38 Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The MDS documented Resident #38 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating. The MDS documented Resident #38 required a mechanically altered diet (requiring a change in texture) of foods or liquids. The MDS documented Resident #38 with a swallowing disorder where coughing, choking during meals or when swallowing medications could occur. The MDS listed diagnoses of cerebrovascular accident (CVA), seizure disorder and dysphagia. The Care Plan initiated on 8/29/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to maintain a Foley catheter bag and tubing off the floor for one of two residents (Resident #18), and failed to provide adequate incontinent care to one out of three residents reviewed (Resident # 2). The facility identified a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #18 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 12 out of 15. The MDS diagnoses list: atrial fibrillation (an abnormal heart rhythm), obstructive uropathy (a condition in which the flow of urine is blocked). The MDS identified Resident #18 with an indwelling urinary catheter. Per the MDS, Resident #18 totally dependent on staff for toileting, lower body dressing; substantial staff assistance with showers, upper body dressing repositioning and transfers. On 7/22/22, the Care Plan identified Resident #18 with a Focus Area related to an indwelling catheter. An observation on 8/12/24…

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, resident, and staff interviews the facility failed to provide on going assessments and monitoring of a resident condition before and after dialysis treatments for 1 of 1 residents (Resident #38) who receive Dialysis services. Facility reported a census of 61 residents. Findings include: 1. Resident #38 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS identified Resident #38 receives dialysis services. The MDS listed diagnoses of renal insufficiency, renal failure and end stage renal disease (ESRD). The Care Plan initiated on 8/29/23 identified Resident #38 receives hemodialysis on Monday, Wednesday and Friday, with the goal that the resident will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date. The Care Plan lacked an intervention to direct staff to assess resident condition before and…

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

Based on observation, staff interviews and record review the facility failed to properly puree food to a physician ordered texture for 2 out of 2 residents reviewed on a pureed diet. (Resident # 13 and Resident #39 ). The facility reported a census of 61 residents. Findings include: During an observation on 08/12/24 at 12:10 PM, food served in the main dining room of pork loin, baked potato and broccoli. There was 2 residents being assisted to eat and were served mashed potatoes, ground meat and pureed broccoli. During an interview on 08/12/24 at 12:17 PM, the Dietary Manager stated stated the pureed meat should be a soft texture and it should stay on the spoon. The vegetable pureed and it should be like pudding and the meat should be thick but smooth. Surveyor asked her to look at the meat on Resident #39 & Resident #13 plate and she stated the meat being served is thick and more like ground meat. It should be smooth. The State Agency intervened and asked her to remove plates from residents Resident # 39 & Resident # 13. During an interview on 08/12/24 at 12:21 PM Staff 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 and staff interview, the facility failed to provide rehabilitation services in accordance with physician orders for 1 of 3 residents reviewed (Resident #3). The facility reported census was 60. Findings include: The Order Summary Report dated 12/29/23 listed an order for a physical therapy evaluation and treatment as needed. The Physical Therapy (PT) Evaluation and Plan of Treatment report with a certification period of 1/2/24 - 2/1/24 signed by the Physical Therapist and Resident #3's primary care physician (PCP) directed Resident #3's PT frequency as five times a week. On 6/19/24 at 10:40 AM, Staff J, Physical Therapy Assistant (PTA), reported Resident #3 should have had physical therapy services five times per week. Staff J stated he didn't recall Resident #3 refusing therapy and noted she made good progress towards the end of her stay. The Physical Therapy Treatment Encounter Note(s) reflected Resident #3 had PT services one time during the week of January 7 13 and 14 20, then only twice during the week of February 11 17. During that same time,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to implement directives as required and stipulated in a resident's Level II PASRR (Pre admission Screening and Resident Review), for 1 of 3 resident records reviewed with Level II PASRR requirements (Resident #8). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 2/6/24 revealed Resident #8 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure, hypertension (high blood pressure), respiratory failure, asthma, and non-Alzheimer's dementia. The Resident scored 5 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment, without symptoms of delirium present, and required extensive assistance by at least 1 staff member to reposition in bed, transfer to and from bed or wheelchair, dressing, bathing, and toilet use. The resident's record listed a family member as 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to follow a resident's Nursing Care Plan for 1 of 9 resident records reviewed (Resident #1). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 2/6/24 revealed Resident #1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), peripheral vascular disease, aphasia (inability to speak following a cerebrovascular accident, also called a stroke), hemiplegia (paralysis of 1 side of the body) following cerebral infarction that affected the right dominant side of the body, and depression. The resident scored 12 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated mild cognitive impairment, without symptoms of delirium present, the resident usually able to make herself understood and usually able to understand others. The MDS assessment revealed the resident required extensive…

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, facility staff, Hospice staff and hospital staff interviews, the facility failed to provide baths and bathing assistance to 6 of 16 residents reviewed in the open sample, (Resident's #8, #11, #27, #64, #66 and #258). The facility reported a census of 57 residents. Findings Include: Review of the facility's required Plan of Correction (POC), related to this deficiency, identified concerns for Resident's #11 and #27, cited during the Annual Recertification Survey completed 10/12/23, with 11/7/23 identified as the date of credible compliance, stated: a. Resident's #11 and #7 are receiving their baths/showers per their wishes. b. Staff were educated on 10/11/23 on the requirement to complete baths according to the resident's Care Plan and wishes. c. The Director of Nursing (DON)/Designee will audit the bathing schedule 3 times a week for 3 weeks and then monthly for 3 months to monitor. Morning Meeting staff will monitor that audits occur and appropriate corrective actions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the Centers for Medicare and Medicaid Services (CMS), Certification and Survey Provider Enhanced Reporting System ([NAME]), observations, clinical record review, staff and resident interviews, the facility failed to ensure effective measures were taken to correct deficiencies that continue to be cited, including self-administration of medication, timely Preadmission Screening and Resident Review (PASRR) submissions, Activity of Daily Living (ADL) assistance and administration of annual Influenza and Pneumococcal vaccinations. The facility reported a census of 57 residents. Findings Include: Observations throughout the investigation, clinical record review, staff and resident interviews revealed the facility had not corrected some of the deficiencies cited during their Annual Recertification Survey completed 9/12/23 to 10/12/23, and resulted in continued deficiencies for self-administration of medication (F 554), submission of PASRR Assessments (F 644), provision of Activity 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 clinical record review, observations, resident and staff interviews, the facility failed to ensure a resident was assessed for self-administration of medications and failed to obtain a Physician's Order for the resident's self administration of medications, for 1 of 3 resident's reviewed for self-administration of medications (Resident #61). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) Assessment tool dated 9/18/23 revealed Resident #61 had diagnoses that included congestive heart failure, anemia and hypertension, and scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive impairment or symptoms of delirium present. The resident required extensive assistance/support by at least 1 staff for transfers to and from bed and chair, dressing, toileting and bathing. Physician Orders directed staff to administer medications that included: a. Verapamil (a calcium channel blocker for heart conditions), 120 milligrams (mg) administered oral daily, ordered…

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 interviews, the facility failed to re-submit the Preadmission Screening and Resident Review (PASARR) Assessments following a change in condition, and after identified as a deficiency on the previous Annual Recertification Survey, for 3 of the 4 residents cited in the previous survey (Resident's #20, #21 and #24). The facility reported a census of 57 residents. Findings Include: 1. The [DATE] Minimum Data Set (MDS) Assessment tool revealed Resident #20 had diagnoses that included bipolar disorder, anxiety, depression and post traumatic stress disorder (PTSD), scored 15 out of 15 possible points on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive impairment or symptoms of delirium, and received antipsychotic, antidepressant and antianxiety medication on 7 of the 7 days that preceded the assessment. Review of the PASARR dated [DATE] in the Electronic Health Record (EHR) revealed the resident had a negative Level 1 Screen…

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 staff, Hospice staff and Hospital staff interviews, the facility failed to provide timely assessments and implement appropriate interventions when a change in a resident's condition was identified, and failed to implement a Physician Order for antibiotic to treat a resident's leg infection, for 1 of 19 resident records reviewed (Resident #64). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) Assessment tool dated 11/3/23 revealed Resident #64 had diagnoses that included congestive heart failure, pneumonia with oxygen dependence, anxiety and schizophrenia, scored 6 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated severe cognitive impairment, without symptoms of delirium present, always able to make himself understood and always able to understand others, and dependent on staff assistance for dressing, toileting and bathing. Physician Orders directed staff to administer…

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, observations, and staff interviews, the facility failed to ensure employees hired as Nurse Aides did not continue to work at the facility after 4 months as per requirements, unless the employee was competent to provide nursing and nursing related services, and the employee had completed a training and competency evaluation program and certified through the program, for 2 Nurse Aides hired 8/2/23 (Staff B and Staff E). The facility reported a census of 57 residents. Findings Include: Staff B and Staff E were both hired as Hospitality Aides on 8/2/23, to work as Nurse Aides at the facility while enrolled in the Certified Nursing Assistant (CNA) course at a local Community College. Review of their personnel files on 11/29/23 revealed the employee's did not have a Skills Competency Checklist, or other documentation that verified their competencies in the basic and essential duties completed by Nurse Aides, and as required. The files lacked documentation that the employee's were enrolled in the required CNA course, or their testing/completion 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident responsible party interviews, the facility failed to seek and obtain appropriate authorization for administration of the annual Influenza vaccine, for 2 of the 4 residents identified in this deficiency on the previous Annual Recertification Survey completed 10/12/23. Both resident had not received the vaccination (Resident's #21 and #52) as of the current review. The facility reported a census of 57 residents. Findings Include: 1. The MDS Assessment Tool, dated 8/26/23 revealed Resident #21 had diagnoses including congestive heart failure, hypertension (high blood pressure) schizoaffective disorder, anxiety disorder and non-Alzheimer's dementia. A cognitive assessment was not completed on the assessment, the MDS revealed the resident had symptoms of delirium present, both short and long-term memory deficits, and moderate cognitive impairment. The resident was usually able to make himself understood, had difficulty communicating some words or thoughts, but able…

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, clinical record review, staff interviews, review of the Infection Control Nurse Job Description and review of Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to implement additional Personal Protective Equipment (PPE) for 1 of 1 residents (Resident #35) on Enhanced Barrier Precautions, to prevent the spread of contagious microorganism during wound care. Failed to ensure the Infection Preventionist (IP) had completed the specialized training in Infection Prevention and Control, resulting in lack of staff knowledge and adherence to enhanced barrier precautions. Failed to ensure the wound vac machines and tubing remained off the floor for 2 of 2 residents with wound vacs (Residents #24 and #38), and ensure clean resident clothing was delivered in a covered cart. The facility reported a census of 56 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #35 as cognitively impaired with a Brief Interview for Mental…

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, clinical record review, resident and staff interviews, review of Resident Council Meeting Minutes, and facility policy review, the facility failed to provide a respectful, dignified environment and care to 4 out of 12 residents reviewed (Residents #11, #16, #17, #29, #39 and #41). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #11 dated 8/15/23, reflected a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating intact cognition. The MDS reflected Resident #11 independent with toileting and transfers. The Care Plan for Resident #11 dated 5/4/23, identified her independent with transfers, and continent of bowel and bladder (B&B) at times may have incontinent episodes and wears incontinence material for dignity. The Care Plan continued to direct, promote dignity by ensuring privacy. On 9/18/23 at 11:17 AM, as Resident #11 sat in her room dressed well, she reported a lot of staff failed to knock and 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 clinical record review, staff interviews, and facility policy review, the facility failed to ensure submission, and resubmission of the Preadmission Screening and Resident Review (PASARR) following admission and a change in medical diagnosis for 4 of 6 residents reviewed (Residents #16, #20, #21, and #24). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/30/23, listed diagnoses for Resident #16 included: Bipolar disorder, and depression. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan dated 8/24/22, revised on 3/27/23 documented, The resident uses psychotropic medications related to (R/T) behavior management. Review of the PASARR, dated 2/11/22, revealed an outcome of NO Level II required. The PASARR documented the resident had no mental health diagnoses known or suspected. A review of the resident's medical diagnosis list in the Electronic Health Record (EHR) revealed a diagnosis of: a. Bipolar disorder with onset…

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, clinical record review, resident and staff interviews, and facility policy review the facility failed to ensure two out of two residents reviewed for use of antipsychotic medication were prescribed the medication for an accurate diagnosis (Residents #16, and #48). The facility also failed to follow Physician Orders for two of three residents reviewed for following Physician Orders (Residents #17 and #108). The facility reported a census of 56 residents. Findings Include: 1. The admission Minimum Data Set (MDS) Assessment for Resident #48 dated 8/15/22, included diagnoses of thyroid disease, malnutrition, and adult failure to thrive. The MDS failed to identify psychiatric mood disorders. The MDS identified the Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS reflected Resident #48 failed to exhibit behaviors. The MDS documented Resident #48 took antipsychotic medication. The History and Physical for Resident #48 dated 7/15/22, 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 observations, clinical record review, staff interviews and facility policy review the facility failed to provide complete assessments for 4 out of 6 residents reviewed for skin (Residents # 24, #37, #38 and #44). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident#44 dated 7/16/23, included diagnoses of cerebrovascular accident (CVA), and post thrombotic syndrome. The MDS reflected no memory problems and moderately impaired daily decision making skills. The MDS reflected Resident #44 skin conditions included two arterial ulcers. The Care Plan for Resident #44 dated 7/26/2022, identified an arterial ischemic (inadequate blood flow) ulcer of the on both lower extremities. The Care Plan directed nursing staff on the following interventions: a. Monitor/document wound: Size, depth, margins: periwound (the surrounding area of the wound edge) skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. 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 observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure catheter bags and tubing were off the floor for 4 of 6 residents reviewed with indwelling catheters and urostomies (a surgically constructed opening in the urinary tract allowing urine to exit the body) (Residents #17, #24, #26 and #38). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/8/23 , listed diagnosis for Resident #26 included: Diabetes mellitus type 2, respiratory failure, and obstructive uropathy (blocked urine flow). The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 of 15, indicating intact cognition. The Care Plan dated 4/26/23 documented, Indwelling Catheter related to: Neurogenic bladder (lack control of bladder). A review of the Electronic Health Record (EHR) diagnosis list lacked a diagnosis of neurogenic bladder. The EHR revealed physician orders to: a.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident, family and staff interviews, and review of Resident Council Meeting Minutes, the facility failed to answer call lights in a timely manner for seven of seven residents reviewed (Residents #10, #16, #24, #27, #38, #44, #108). The facility reported a census of 56 residents. 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #10 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 and had the following diagnoses: Fractures and Other Multiple Trauma, Peripheral Vascular Disease and Diabetes Mellitus. The MDS documented Resident #10 required extensive staff assistance with bed mobility, transfers, toileting and bathing. In an interview on 9/12/23 at 9:23 AM, Resident #10 reported when she turns on her call light, the longest she had to wait was an hour on 2nd shift. There was a clock in her room highly visible from her bed and recliner. She has had falls trying to get herself to the toilet because she got tired…

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 Incident Reports and staff interviews, the facility failed to follow Physician Orders which resulted in medication errors for 4 of 4 residents reviewed (Residents #1, #27, #29 and #60). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and had the following diagnoses: Sepsis (when an infection you already have triggers a chain reaction throughout your body), Coronary Artery Disease and Heart Failure. The MDS also identified Resident #1 required extensive staff assistance with bed mobility, dressing, personal hygiene and bathing and totally dependent on staff for transfers, locomotion on and off the unit and toileting. A review of an Incident Report dated 6/22/23 at 2:32 PM, revealed Resident #1 had received another resident's morning medication of Metoprolol 25 milligrams (mg) administered by Staff…

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

Based on observation, staff interviews, review of the Staff Identification List, and Position Summary Review, the facility failed to meet the required qualifications for a dietary professional position for 1 of 1 Food Service Directors reviewed. The facility reported a census of 56 residents. Findings Include: On 9/19/23 at 11:15 AM, observed Food Service Director assist the [NAME] in kitchen during lunch service. Food Service Directed plated and sent out room trays to the hallways. On 9/25/23 at 4:00 PM, Director of Nursing (DON), reported that the current Food Service Director was in the process of taking classes for a Certified Dietary Manager (CDM) certificate. On 9/26/23 at 1:00 PM, the Food Service Director explained that she has been in her current position for approximately 1 year and started taking classes in April or May of this year for her CDM. Food Service Director reported that no other staff is currently CDM certified and informed that the Dietitian visits about two times per week. Review of Key Personnel list, not dated, provided by facility, revealed Food Service…

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

Based on observation, staff interviews, and facility policy review, the facility failed to ensure food brought in by family or other visitors was handled properly to ensure safety of the residents for 1 of 1 unit refrigerators observed. The facility reported a census of 56 residents. Findings Include: On 09/26/23 at 11:30 AM, the following observations of the [NAME] Hallway unit refrigerator labeled as Resident Refrigerator and Freezer were made: a. [NAME] stains covering the outside of fridge. b. Crumbs and stains on racks, drawers, and bottom of fridge. c. Many undated Tupperware containers with different food items. d. One dated Ziploc bag indicated it is from 8/24/23. e. Two bottles of expired mayonnaise found in fridge door (1 expired July 2022 and 1 expired August 16th 2023). f. Two 2% milk cartons of milk expired 9/02/23. f. One chocolate milk carton expired 9/03/23. g. Also noted 7 dates on fridge temp log for the month of September without a temperature recorded. On 9/26/23 at 12:00 PM, Assistant Director of Nursing notified that Dietary Department is responsible 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 staff interviews, clinical record review, recommendations by Centers for Disease Control and Prevention (CDC), and facility policy review, the facility failed to screen for eligibility, offer, provide education, and document vaccine consent or refusal for pneumococcal, influenza, and/or Coronavirus vaccinations to residents and/or resident representatives for 4 out of 5 residents reviewed for vaccination documentation (Resident #8, #10, #21, and #52). The facility reported a census of 56 residents. Findings Include: On 9/27/23 at 1:19 PM, Director of Nursing (DON), reported all Immunizations Records were located in Resident Electronic Health Records (EHR) within the immunization tab and resident assessment tab. DON stated the facility does not offer pneumococcal vaccination unless requested. 1. A review of the Immunization Records revealed Resident #8 SARS-CoV-2 vaccination as consent refused without date documented, without documentation of education provided to Resident #8. Documentation of Pneumovac…

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, clinical record review, resident and staff interviews, and facility policy review, the facility failed to complete self-medication assessments, and obtain a Physician Order to self-medicate for 5 of 5 residents in the sample (Residents #7, #27, #37, #38 and #258). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/21/23, listed diagnoses for Resident #27 included spina bifida, chronic obstructive pulmonary disease (COPD), and weakness. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During the following observations, the medications diclofenac sodium gel 1%, fluticasone-salmeterol inhaler, and albuterol inhaler were found to be in the residents room, sitting on the bedside table: a. On 9/18/23 at 9:43 AM. b. On 9/20/23 at 9:45 AM. c. On 9/21/23 at 9:00 AM. d. On 9/25/23 at 9:45 AM. A review of the clinical record revealed physician orders 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 clinical record review, staff interview and policy review the facility failed to provide accurate documentation of Advanced Directives according to resident wishes for 1 of 3 residents reviewed for Advanced Directives. The facility reported a census of 56 residents. Findings Include: The Minimum Data Set (MDS) identified Resident #258 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. It also identified the resident with the following diagnoses: Stroke, Atherosclertic Heart Disease and Renal Insufficiency. A review of Iowa Physicians Orders for Scope of Treatment (IPOST) document shown Resident #258 requested to be a Do Not Resuscitate (DNR), comfort care measures only. Resident #258 signed the IPOST on [DATE], The Nurse Practitioner signed the IPOST on [DATE]. Resident #258 selected her preference for no transfer to hospital for life-sustaining treatment, transfer if comfort needs cannot be met in current location. A review of the Physician Order Summary, dated…

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, family and staff interviews, and facility policy review, the facility failed to notify a resident's Power of Attorney (POA) of an allegation of potential abuse for one of one residents reviewed (Resident #52). The facility reported a census of 56 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #52 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 0 and had the following diagnoses: Non-traumatic Brain Dysfunction, Dementia with Mood Disturbance and Diabetes Mellitus. The MDS documented Resident #52 required extensive staff assistance with transfers, dressing and bathing and totally dependent on staff for toileting. On 4/3/23, the Care Plan identified Resident #52 with the problem of Impaired cognitive function/dementia or impaired thought processes Dementia, Developmentally delayed, Difficulty making decisions, Impaired decision making, Neurological symptoms, Poor nutrition and directed staff to communicate…

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, clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents wheelchairs were clean for 3 of 3 residents in the sample (Residents #26, #33, and #52). Residents #20 and #108 and Resident Council Members reported rooms were not cleaned daily. The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/8/23 , listed diagnosis for Resident #26 included: Diabetes mellitus type 2, respiratory failure, and obstructive uropathy (blocked urine flow). The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 of 15, indicating intact cognition. During an observation on 9/27/23 at 10:25 AM, while sitting in his wheelchair in his room, the resident's wheelchair wheels found to have: a white dust like substance covering his foot rest with a heavy build up in the corners; the right and left sides, and back black frame components covered in the white dust…

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 Incident Report and staff interview, the facility failed to report an allegation of possible abuse to the State Agency in a timely manner for one of one residents reviewed (Resident #52). The facility reported a census of 56 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #52 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 and had the following diagnoses: Non-traumatic Brain Dysfunction, Dementia with Mood Disturbance and Diabetes Mellitus. The MDS documented Resident #52 required extensive staff assistance with transfers, dressing and bathing and totally dependent on staff for toileting. A review of a facility Incident Report dated 9/1/23 with a time 1:20 p.m.: Nursing Description: Director of Nursing (DON) was notified via staff that there was an allegation of physical abuse towards a resident from another staff member. DON went directly to source that reported the witness of abuse.…

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 incident report and staff interview, the facility failed to follow the facility policy after a report of an allegation of possible abuse for one of one residents reviewed (Resident #52). The facility reported a census of 56 residents. Findings include: The Minimum Data Set, dated [DATE] identified Resident #52 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 and had the following diagnoses: Non-traumatic Brain Dysfunction, Dementia with Mood Disturbance and Diabetes Mellitus. The MDS documented Resident #52 required extensive staff assistance with transfers, dressing and bathing and totally dependent on staff for toileting. A review of a facility Incident Report dated 9/1/23 with a time 1:20 p.m.: Nursing Description: The Director of Nursing (DON) was notified via staff that there was an allegation of physical abuse towards a resident from another staff member, former Business Office Manager (BOM). The DON went directly to 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 observations, clinical record review, staff and resident interview, and facility policy review the facility failed to complete baths, as directed in Care Plans and according to resident wishes and failed to ensure resident are clean for three out of seven residents reviewed (Residents #11, #27 and #52). The facility reported a census of 56 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #11 dated 8/15/23, included diagnoses of diabetes mellitus and weakness. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS documented Resident #11 required extensive assist of 1 staff for bathing. The Care Plan for Resident #11 dated 5/21/23, directed two baths or showers a week per her request, but she frequently chooses to take only 1 bath a week. The Bath Record in the Electronic Health Record (EHR) for Resident #11 dated June 2023, showed the facility failed to proved 7 bathes for the month. The Bath Record 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 observation, clinical record review, staff interviews, the facility failed to ensure the residents' feet were placed on the wheelchair foot pedals during transport to prevent any injuries for residents in wheelchairs for two of three residents observed (Residents #17 and #36). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #17 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had the following diagnoses: Hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), Obstructive Neuropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and other fracture. In an observation on 9/19/23 at 12:02 PM, Staff Z, Receptionist pushed Resident #17 into the main dining room in a wheelchair without foot pedals and Resident #17's feet dragging on the floor. On 6/10/20, the Care Plan identified Resident #17 with the problem 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 observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure a Physician Order obtained for the use of oxygen for 2 of 2 residents in the sample (Residents #18 and #20). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment tool, dated 7/21/23, listed diagnosis for Resident #18 included: Cerebrovascular accident (stroke), chronic obstructive pulmonary disease (COPD), and pressure ulcer of sacral region stage 4. The MDS identified the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicating intact cognition. The MDS documented the resident does not currently use oxygen. During an observation on 9/18/23 at 1:51 PM, noted an oxygen concentrator in the resident's room running at 3 liters/minute with the tubing hanging on the resident's bedrail. During an interview on 9/18/23 at 1:52 PM, the resident stated she uses oxygen throughout the day and wants 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, resident and staff interviews, and policy review, the facility failed to provide ongoing assessment of resident condition and monitoring for complications before and after Dialysis treatments for 1 of 1 residents who received Dialysis services (Resident #258). The facility reported a census of 56 residents. Findings Include: The Minimum Data Set (MDS), dated [DATE] identified Resident #258 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and had the following diagnoses: renal insufficiency, renal failure, and End Stage Renal Disease (ESRD). The MDS also identified Resident #258 required Dialysis services. A review of the Physician Order Summary dated 8/26/23 revealed no Dialysis orders in place. On 8/29/23, the Care Plan, identified the resident required hemodialysis with the goal that resident would have immediate intervention should any signs or symptoms of complication from dialysis occur through the review date. The Care Plan…

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, Pharmacy policies, and staff interviews, the facility failed to ensure medications were properly labeled when obtained from an automatic dispensing unit for 1 of 9 residents in the sample. The facility reported a census of 56 residents. Findings Include: During a medication administration observation on 9/20/23 at 12:58 PM, Staff M, Licensed Practical Nurse opened a packet of medications for Resident #13 to remove one of three medications. Staff M removed baclofen 10 milligrams (mg) 1 tablet to administer to the resident. Staff M then used a piece of tape to close the packet with the following medications remaining inside: a. Hydralazine HCL 100 mg 1 tablet b. Gabapentin 100 mg 1 tablet. Staff M then used a black marker to cross out the baclofen from the packet label. During an interview on 9/20/23 at 2:53 PM, Staff M stated she pulled the baclofen for the morning dose. However the other medications were not due to be administered until 3:00 PM. Staff M explained the third shift pulls medication out of an automatic dispensing unit, and there are times when 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 the Centers for Medicare and Medicaid Services (CMS), Certification and Survey Provider Enhanced Reporting system ([NAME]), review of the facility Quality Assurance Performance Improvement (QAPI)) Plan and staff interview the facility failed to ensure effective measures had been taken to correct deficiencies that continue to be cited. The facility reported a census of 56 residents. Findings include: A review of the CMS CASPER reports revealed the following deficiencies had been cited as follows: a. F677 Activities of Daily Living in 2019 and 2022 . b. F684 Assessment/Intervention in 2020 and 2022. c. F725 Sufficient Staffing/Call Lights in 2019, 2020 and 2022. d. F812 Storage in the Kitchen in 2019, 2020 and 2022. e. F880 Infection Prevention in 2019, 2020 and 2022. All of the above deficiencies will be cited again in 2023. A review of the facility QAPI Plan revealed the following: The QAPI Committee utilizes a systematic approach to performance improvement, including analysis of data, corrective action…

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.