Accura Healthcare of Carroll

Based on clinical record review, staff interview and guidance from the 2025 Resident Assessment Instrument (RAI) manual, the facility failed to complete and transmit a Minimum Data Set (MDS) assessment within federal guideline for 2 of 2 resident reviewed for MDS assessments (Resident #4 and #17). The facility reported a census of 48 residents. Findings include: 1. Review of the census tab in the electronic health record (EHR) revealed Resident #4 was discharged on 1/7/26. The Progress Note on 1/7/26 indicated Resident #4 had been discharged to Assisted Living. The MDS section of the EHR revealed a discharge MDS had not been set up or completed. 2. Review of the census tab in the EHR revealed Resident #17 was discharged on 2/10/26. The Progress Note on 2/10/26 indicated Resident #17 had returned home. The MDS section of the EHR revealed a discharge MDS had not been set up or completed. On 3/30/26 at 3:48 PM, the Interim Director of Nursing (DON) acknowledged Resident #4 and Resident #17 discharge MDS was not completed. She said a discharge MDS was expected to be completed when 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 clinical record review, staff interviews, and pharmacist interview, the facility failed to intervene and call the pharmacy and follow up with a physician when medication was unavailable for 1 of 6 residents reviewed (Resident #51). The facility reported a census of 48 residents.Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #51 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included fractures and other multiple trauma, a seizure disorder, a mood disorder, and mild cognitive impairment. The Care Plan initiated 12/11/25 identified Resident #51 at risk for adverse effects from the routine/as needed (PRN) use of anticonvulsants. The resident had a diagnosis of epilepsy. Interventions included observing for the effectiveness of medications, reporting significant side effects to the physician, and reviewing medications as necessary. The Medication Administration Record (MAR) for December…

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, clinical record review and policy review the facility failed to give medications according to manufacturer's instructions for 2 out of 5 residents observed during medication pass (Resident #24 and #14). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #24 dated 2/11/26 identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #24 was independent with bed mobility and transfers. The MDS included diagnoses of non-alzheimer's dementia, seizure disorder and anxiety disorder. The April 2026 Medication Administration Record (MAR) directed staff to administer Fosamax (used to treat or prevent osteoporosis) 70 MG (milligrams) one tablet by mouth one time a week in the Early AM on Wednesday related to osteoporosis. The order lacked specific directions on how the medication should be administered. During observation with the morning medication pass on 4/1/26 with Resident #24 and review of April 2026 MAR revealed 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 interviews, and Pharmacy interview, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents reviewed (Resident #51). The facility reported a census of 48 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #51 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included fractures and other multiple trauma, a seizure disorder, a mood disorder, and mild cognitive impairment.The Care Plan initiated 12/11/25 identified Resident #51 at risk for adverse effects from the routine/as needed (PRN) use of anticonvulsants. The resident had a diagnosis of epilepsy. Interventions included observing for the effectiveness of medications, report significant side effects to the physician, and review medications as necessary. 1. The Medication Administration Record (MAR) for December showed the resident to receive Cenobamate…

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 interviews, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 15 residents (Residents #2, #5, and #45) reviewed. The facility reported a census of 48 residents.Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Interview on 3/30/26 at 11:35 AM with Resident #2 revealed the food that comes on lunch trays is often cold, and not warm when it is delivered. 2. Review of Resident #5's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognitive functioning. Interview on 3/30/26 at 11:14 AM with Resident #5 revealed the food is often cold when it is delivered on room trays when it should be hot. 3. Review of Resident #45's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. Interview on 3/30/26 at 10:32 AM with Resident #45…

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, resident interview, staff interviews, and policy review the facility failed to use universal infection control measures (hand hygiene) during care of two separate wounds for 1 of 5 residents reviewed for infection control (Residents #2). The facility reported a census of 48 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Further review of the MDS revealed Resident #2 had diagnoses of hypertension (high blood pressure), diabetes mellitus, stroke, and a stage 3 (full-thickness skin loss injury) pressure ulcer to the right buttocks. Interview on 3/30/26 at 11:37 AM with Resident #2 revealed that there were open areas to her buttocks. Resident #2 further revealed the areas to her buttocks are getting dressing changes. Review of Resident #2's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed 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 clinical record review, facility document review, staff interviews and resident interviews, the facility failed to answer call lights in a timely manner for 4 of 4 residents reviewed (Resident #3, #4, #5 and #6). The facility reported a census of 52 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS documented the resident was dependent on staff for toileting hygiene, showering, dressing, rolling left and right, transfers and mobility in the wheelchair. The resident's diagnoses included diabetes, a fracture (ankle), and chronic obstructive lung disease.On 12/22/25 at 3:11 p.m. Resident #3 stated she didn't keep time for call lights, but had to wait a long time on weekends to get the light answered. A review of Resident #3's call light logs for the previous 2 weekends revealed:On 12/14/25 at 8:31 a.m. a call light of 31 minutes.On 12/14/25 at 10:32…

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 interview, staff interview, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner. The facility reported a census of 47 residents.Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity. Interview 10/14/25 at 10:30 AM with Resident #1 revealed that call lights take longer than 15 minutes often, especially on the evenings and weekends. 2. Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of diabetes mellitus, hyperlipidemia, anxiety disorder, respiratory failure, post polio syndrome, and morbid obesity. Interview 10/14/25 at 2:05 PM with Resident #5 revealed call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to revise and implement care plans for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 47 residents. Findings include: Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity.Review of Resident #1's Care Plan revealed that Resident #1 was at risk for falls related to weakness with an intervention for Resident #1 to have on the proper footwear prior to transfers initiated 1/29/23. The Care Plan further revealed Resident #1 had activities of daily living deficit related to weakness with an intervention for transfers with assistance with two staff with a walker and gait belt dated 1/11/23. Review of a facility provided document titled, Physical Therapy Discharge 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 staff interview, resident interviews, facility documentation and policy review, the facility failed to provide care for 6 out of 15 residents reviewed (Resident #1,#6, #9, #11, #12, #2) in a manner to promote dignity and respect. The facility reported a census of 47 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #1 was dependent on staff for eating. Resident #1's MDS included diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. On 6/18/25 at 9:37 AM, Staff B, Registered Nurse (RN) reported on 6/5/25 during breakfast she observed Resident #1 reached for his plate of food and saw Staff A, Certified Nursing Assistant (CNA) push his hands away. She said Resident #1 reached for the plate of food 3-4 more times and Staff A would swat his hands away. She said each time Staff A would get more and more aggressive with…

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

Based on personnel file reviews, facility policy review and staff interviews, the facility failed to provide dependent adult abuse (DAA) recertification training within 3 years for 1 of 2 employees reviewed. The facility identified a census of 47 residents. Findings include: The personnel file for Staff A, Certified Nursing Assistant (CNA) documented a hire date of 5/15/24. Review of the Dependent Adult Abuse Mandatory Reporter Training Certificate documented Staff A completed the 2 hour dependent adult abuse training on 5/8/22. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 10/19/22 revealed each employee will be required to take a 1 hour recertification training within 3 years of the initial 2 hour training course and every three years thereafter. On 6/17/25 at 11:40 AM, the Administrator reported Staff A did not have an updated DAA certificate. The Administrator stated she was not sure why Staff A had not taken the training. She said the facility had an excel spreadsheet to track the DAA training and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to limit PRN (as needed) antipsychotic drugs to 14 days, failed to have a Physician evaluate for appropriateness of the medication and provide a clinical rationale prior to the antipsychotic medication usage being extended. In addition the facility failed to obtain a clinical rationale when an antianxiety medication usage was extended and also failed to complete behavioral documentation and offer/attempt nonpharmacological interventions prior to the administration of antianxiety medications for 1 out of 3 residents reviewed (Resident #2) for unnecessary medications. The facility reported a census of 47 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS identified Resident #2 as dependent on staff for bed mobility and chair/bed to chair transfers. Resident #2's MDS…

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

Based on facility investigation review, staff interviews and policy review the facility failed to report an allegation of abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 1 of 3 residents reviewed (Residents #1). The facility reported a census of 47 residents. Findings include: A facility form titled Self Report documented on 6/5/25 at 7:35 AM, Staff A, Certified Nursing Assistant was assisting Resident #1 eating his breakfast. During this time Staff B, Registered Nurse (RN), witnessed Staff A push Resident #1's hands away from his plate as he continued to grab towards it. Staff B stated this occurred multiple times before Staff A quickly wheeled Resident #1 away from the table prior to him completing his meal. The documentation revealed Staff B notified the Administrator regarding the allegations of abuse at approximately 3:30 PM on 6/5/25. Review of the document titled Intake Information revealed the facility contacted the State Agency via phone regarding the allegation of abuse for Resident #1 on 6/5/25 at 4:57 PM and completed 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 staff interviews, facility investigation review, time card detail, and policy review the facility failed to separate a staff member from dependent residents accused of alleged abuse that occurred on 6/5/25 at 7:30 AM in a timely manner for 1 of 3 resident reviewed for abuse (Resident #1). The staff member continued to worked her shift and left the facility at 4:40 PM. The facility reported a census of 47 residents. Findings include: A facility form titled Self Report documented on 6/5/25 at 7:35 AM, Staff A, Certified Nursing Assistant was assisting Resident #1 eating his breakfast. During this time Staff B, Registered Nurse (RN), witnessed Staff A push Resident #1's hands away from his plate as he continued to grab towards it. Staff B stated this occurred multiple times before Staff A quickly wheeled Resident #1 away from the table prior to him completing his meal. The documentation revealed Staff B notified the Administrator regarding the allegations of abuse at approximately 3:30 PM on 6/5/25. The form further documented on 6/5/25 at 3:35 PM, the Director of Nursing…

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 clinic record review, staff interviews, family interview and policy review, the facility failed to administer medications per physician orders for 1 out of 3 residents reviewed (Resident #3) for significant medication errors. The facility reported a census of 47 residents. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 08, indicating moderately impaired cognition. The MDS identified Resident #2 required substantial/maximal assistance with bed mobility and transfers. The MDS included diagnoses of cancer, hypertension (high blood pressure), peripheral vascular disease, chronic obstructive pulmonary disease, malnutrition, depression and chronic pain. The MDS documented Resident #3 had a condition or chronic disease with a life expectancy of less than 6 months and received hospice services while a resident at the facility. The MDS documented Resident #3 had received antidepressant medications during the last 7 days. 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 clinical record review, staff interview, and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to accurately reflect the status of 7 of 13 residents in the Minimum Data Set (MDS) Assessments (Resident #1, #5, #20, #30, #34, #35, #41). The facility reported a census of 48 residents. Findings include: 1. The Pre admission Screening and Resident Review (PASRR) of Resident #1, dated 1/27/23, identified the resident to require PASRR Level II Services. (Considered by the State Level II process to have a serious mental illness and/or intellectual disability or a related condition). The PASRR identified the Resident to have diagnoses of Down Syndrome, major depressive disorder, mild intellectual disability and unspecified neurodevelopmental disorder. The PASRR identified specialized services the facility needed to provide to the resident while remaining in the nursing facility. The MDS of Resident #1, dated 8/6/24, failed to document the resident to be considered by 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, staff interview, and review of facility menus, the facility failed to follow the posted menu and serve the appropriate portions for 2 of 2 residents who received pureed diets (Res #25 and Res #35), and failed to serve the ordered therapeutic menu for 6 of 6 residents (Res #1, #6, #18, #30, #38, #43) who were ordered to receive mechanical soft diets. The facility reported a census of 48 residents. Findings Include: Posted lunch menu for 3/10/25: 1 Maple Bacon Chicken Sandwich 4 oz French Fries 4 oz Hot Spiced Beets 1 sq Orange Poppyseed Cake 8 oz Milk The menu spreadsheet documented residents with mechanical soft diet orders should receive orange cake with no poppyseeds and residents with puree diet orders should receive pureed orange cake with no poppyseeds. On 3/10/25 at 12:05 pm, Resident #25 and Resident #38 were observed during noon meal service. The Certified Dietary Manager (CDM) served dessert to both residents, and stated to the staff member sitting at the table that Resident #25 was getting pudding instead of cake because poppyseeds cannot safely be…

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

Based on observation, staff interview, guidance from the 2022 Food & Drug Administration (FDA) Food Code and facility policy review, the facility failed to use proper sanitation and glove use during lunch service, and also failed to regularly clean and monitor the internal temperature of a refrigerator designated for resident food items. The facility reported a census of 48 residents. Findings Include: Initial kitchen walk through was initiated on 3/10/25 at 9:36 am. During the kitchen walk through, the Certified Dietary Manager (CDM) was asked about a policy regarding food brought to the facility by resident families/visitors. She stated there is a refrigerator in the employee break room and that is where those foods are stored. She stated the food gets thrown out if not eaten after three days. On 3/11/25 at 10:42 am, observed the break room resident upright refrigerator/freezer and both the refrigerator and freezer were visibly very soiled. No thermometers were observed. No cleaning logs and no temperature logs were observed. On 3/11/25 at 10:50 am, the State Surveyor entered 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 staff interview, personnel record review and Facility Assessment review, the facility failed to ensure that Certified Nurse Aides (CNA) completed the required 12 hours of in-service training annually, for 3 of 3 personnel reviewed. The facility reported a census of 48 residents. Findings include: According to an untitled facility spreadsheet, Staff A, CNA was hired on 10/20/23, Staff B, CNA was hired on 11/12/23, and Staff C, CNA was hired on 12/21/22. When asked to provide documentation of CNA continuing education on 3/12/25 at 10:19 AM, Staff D, Nurse Manager, said the previous Business Manager (BM) was not keeping track of the CNA education needs in Relias, and Staff B hadn't even been signed up for the Relias access. Staff D said that going forward, the new BM would be running a monthly list of required education for CNA in Relias and monitoring/tracking that it was getting completed. The Facility Assessment section titled: Information About Our Staff Training/Education and Competencies, showed that the facilities training program would include an orientation process…

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, admission record review, family interview, staff interview and facility policy review the facility failed to provide complete information to residents regarding room rates for 4 of 4 residents (Resident #20, #22 #49 and #104) reviewed. The facility reported a census of 48 residents. Findings include: On 3/11/25 at 9:30 AM, a family member for Resident #20 expressed concerns related to billing. A follow up review of the admission documentation revealed that the admission Agreement (AA) dated March 15, 2023, lacked clarification of daily room and board charges. The AA included a line: The Base Rate shall equal $____ per day. The Base Rate is subject to change as herein provided. The blank had been filled in with SNF (Skilled Nurse Facility). The AA for Resident #49 dated 11/26/24 did not include an amount and the letters MCD were written on the line. The AA dated 10/28/24 for Resident #22 lacked information on the room rate and SNF was hand written on the line. On 3/12/25 at 11:52 AM, the Regional [NAME] President of Operations agreed that the room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to complete family notification for 1 of 13 residents reviewed (Resident #35). The facility failed to notify Resident #35's family that an antiviral medication was started due to possible shingles infection. The facility reported a census of 48 residents. Findings include: Resident #35's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) was not completed. A Staff Assessment for Mental Status documented Resident #35 was severely impaired with decision making. Resident #35's MDS included diagnoses of down syndrome and intellectual disabilities. A Progress Note dated 3/4/25 at 9:31 AM documented Resident #35 had 12 intact blisters on his left side and the nurse suspected shingles. The note documented a fax was sent to the Physician. A Progress Note dated 3/4/25 at 6:39 PM documented the facility received a new order to start Valcyclovir (antiviral drug used to treat herpes virus infection…

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, family interview, staff interviews and Facility Assessment review, the facility failed to provide a clean, homelike environment for 2 of 3 residents (Resident #20 and #21) reviewed. The facility reported a census of 48 residents. Findings include: On 3/11/25 at 9:30 AM, a family member for Resident #20 expressed concerns about the cleanliness of the facility and that the room for Resident #20 had spider webs in the corners and dirty floors. In an observation on 3/12/25 at 6:55 AM, it was discovered that there were spider webs in the corner behind the recliner chair in Resident #20's room. The bathroom wall behind the toilet was stained and there was black scattered on the tile and floor. The grout in the tile joints around the area of the stains was gone and the floor corners were heavily soiled. In an observation on 3/12/25 at 8:06 AM, it was found that the bathroom for Resident #21 had similar stains, missing grout and soiled floors as the room for Resident #20. The wall behind and below the toilet had a black substance around the tile and on the floor. On…

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

Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit a Minimum Data Set (MDS) Assessment within federal guidelines for 1 of 13 residents (Res. #45) reviewed for MDS Assessments. The facility reported a census of 48 residents. Findings include: The Census Line portion of the Electronic Health Record (EHR) of Resident #45 documented the resident discharged from the facility on 11/8/24. The Discharge Summary Note documented the resident had discharged on 11/18/25 at 9:45 am. The MDS Section of the EHR, reviewed on 3/11/25, failed to reveal a discharge MDS had been set up or completed. On 3/11/25 at 3:14 pm, the MDS Coordinator stated she sets up discharge MDS Assessments on the day of discharge and the social worker also double checks discharges. She stated she was not sure how she had missed completing the assessment. On 3/12/25 at 4:44 pm, the Nurse Consultant stated the facility does not have a policy regarding MDS completion. She stated they…

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 and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 1 of 3 residents reviewed (Resident #22) with skin impairments. The facility reported a census of 48 residents. Findings include: Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #22 required substantial to maximal assistance with bed mobility and transfers. The MDS included diagnosis of hypertension (high blood pressure), diabetes mellitus, septicemia (life threatening blood infection) and cerebral infarction. The MDS revealed Resident #22 had a stage three pressure ulcer and moisture associated skin damage (MASD). The MDS documented skin and ulcer/injury treatments were in place that included a pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 1 resident reviewed (Resident #22) for falls. The facility failed to complete a root cause analysis (RCA), follow up fall assessments and implement a fall intervention after a fall occurred. The facility reported a census of 48 residents. Findings include: Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #22 required substantial to maximal assistance with bed mobility and transfers. The MDS included diagnosis of hypertension (high blood pressure), diabetes mellitus, septicemia (life threatening blood infection) and cerebral infarction. The MDS documented Resident #22 had one fall with no injury since last assessment. The Care Plan with a date initiated 10/28/24 documented Resident #22 was at risk for fall and…

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

Based on observations, clinical record review, family interview and staff interview, the facility failed to accurately provide physician ordered respiratory services for 3 of 3 residents reviewed (Resident #20, #21, #34). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #20 dated 1/15/25 documented diagnoses which included atrial fibrillation, heart failure, and respiratory failure. The Active Orders Section of the EHR of Resident #20 revealed an order dated 3/29/23 for oxygen at 1-2 liters at all times and CPAP (continuous positive airway pressure) with oxygen at 2 liters when sleeping. On 3/10/25 at 10:47 am, Resident #20 was observed sitting in her recliner, with her oxygen cannula in place in her nares (nostrils). The end of the oxygen cannula was observed lying on the floor, not hooked to her oxygen concentrator. The concentrator was turned on at 2 liters. On 3/11/25 at 9:14 am, a family member of Resident #20 reported having found her oxygen on the floor in the past. He stated she has been sent to out of facility…

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

Based on observation, interview and record review the facility failed to ensure that staff used Enhanced Barrier Precautions (EBP) during resident cares for 1 of 3 residents reviewed. Staff K, Registered Nurse (RN) failed to use the recommended Personal Protective Equipment (PPE) while administering tube feedings to Resident #21. The facility reported a census of 48 residents. Findings include: Nursing Notes for Resident #21 showed the following entries: a. On 3/1/25 at 11:38 PM, Resident #21 was transferred to the hospital. b. On 3/7/25 at 1:02 PM, he returned to the facility totally dependent on staff assistance for transfers, toileting and meals. c. On 3/7/25 at 9:07 PM tube feedings initiated. In an observation on 3/11/25 at 6:30 AM, Resident #21 was sitting in his recliner in his room with nasal cannula supplemental oxygen. The resident had some difficulty answering questions as his speech was soft with limited words. Staff K said that the resident had recently returned from the hospital with a feeding tube due to aspiration pneumonia. Staff K prepared the tube feedings and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interviews, staff interviews and policy review the facility failed to establish a pest control program and failed to implement measures to eradicate and contain household pests for 2 of 3 residents reviewed. On 12/8/24 staff reported bugs in the room of Resident #1 and #2. The staff did not know what steps to take to mitigate the spread of what was later identified as bed bugs. The facility reported a census of 53 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 (moderate cognitive deficit.) He required substantial assistance with dressing and hygiene, and was totally dependent on staff for transfers and toileting. His diagnosis included heart failure, renal insufficiency, diabetes mellitus and non-Alzheimer's dementia. The Care Plan for Resident #1 last updated on 5/3/24, showed that he was independent with the use of a wheelchair and he had right sided paralysis.…

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

Based on observations, staff interviews, and policy reviews the facility failed to store, prepare, serve, and distribute food in accordance with professional standards. The facility reported a census of 50 residents. Findings include: On 5/6/24 at 11:53 AM observed Staff A, Cook/Dietary, serve a portion of the noon meal. Staff A wore gloves and touched the bun wrapper, serving utensils, and the buns while preparing Philly Steak Sandwiches. Continuous observations on 5/7/24 at 11:07 AM identified the Dietary Manager (DM), also the cook during this observation, don/doff gloves with inconsistent hand hygiene. The DM removed gloves and placed them on the serving line, donned new gloves, and continued to serve meals over the dirty gloves. Staff A removed gloves worn while handling meal/dietary need cards, donned new gloves to make a peanut butter and jelly sandwich. With new gloves Staff A opened the bread bag, obtained 2 slices of bread, carried them to the preparation station. Staff continued to prepare the sandwich touching the bread after holding the containers of peanut butter and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer residents with an initial negative Level I result for the Pre-admission Screening and Resident Review (PASRR), with a newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 of 4 residents (Residents #14) reviewed. The facility reported a census of 50 residents. Findings include: Review of Resident #14 ' s Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS further revealed diagnosis of non-Alzheimer's dementia, depression, and bi-polar disorder. Review of a facility provided document titled, Notice of PASRR Level 1 Screen Outcome, dated 8/11/21 for Resident #14 revealed a diagnosis of major depression. The Level I Outcome: Level I Negative, No Status Change. The Rationale included: no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to ensure as needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for 1 of 5 residents (Resident #52) reviewed. The facility reported a census of 50 residents. Findings include: Review of Resident #52's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1out of 15, indicating a severe cognitive impairment. The MDS listed diagnosis of diagnosis of Alzheimer's disease, anxiety, and depression. Review of the Clinical Physician's Orders, revealed an order for lorazepam (anti-anxiety medication) intensol oral concentrate 2 mg/ml (milligrams per milliliter). Give 0.25 ml every 1 hour PRN for anxiety/restlessness/agitation. This order lacked a specified stop date. Review of the Medication Administration Records (MAR) from 3/22/24 through 5/7/24 revealed the PRN order for lorazepam intensol oral concentrate was given 15 times in the month of…

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

Based on facility record review, staff interviews, and policy review, the facility failed to implement a system to consistently and accurately reconcile controlled medications. The facility reported a census of 58 residents. Findings include: A facility form titled Monthly Narcotic Count Record labeled Medication Cart 100 indicated the staff who signed the form, acknowledged the transfer of responsibility for the narcotic count and have found the quantity counted of each medication agreed with the quantity stated on the Individual Narcotic Count Record. The record required the Nurse's on signature and the Nurse's off signature for each shift. The review of the count record for Medication Cart 100 lacked staff signatures, indicating the reconciliation of controlled medications for Medication Cart 100 didn't occur on the following shifts: a. February 2024 - 2/1/24 - 2-10 shift on - 2/3/24 - 2-10 shift off - 2/4/24 - 2-10 shift off - 2/8/24 - 2-10 shift on and off - 2/14/24 - 2-10 shift off - 2/21/24 - 2-10 shift on and off - 2/22/24 - 10-6 shift off - 2/28/24 - 6-2 shift on and off 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.

Based on observations, staff interviews and policy review, the facility staff failed to keep medication cart locked while unattended by staff in a resident common area. The facility reported a census of 58 residents. Findings include: On 3/11/24 at 8:20 AM observed a medication cart unlocked in a resident common area near the 200 hallways without staff presence. Staff A, Licensed Practical Nurse (LPN) returned to the medication cart and locked it during the observation. On 3/13/24 at 1:25 PM, observed a medication cart unlocked in a resident common area near the 200 hallways without staff presence. The Director of Nursing (DON) acknowledged the unlocked medication cart and locked the medication cart herself. She stated she would educate the staff regarding the need to lock the medication cart. On 3/13/24 at 1:52 PM, Staff A verified she left the medication cart unlocked and unattended on 3/11/24 and on 3/13/24. She stated she knows the expectations and the DON talked to her on Monday and again on 3/13/24. Staff A stated a resident needed his blood sugar done right away and she left…

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 interview, resident interview, and facility documentation, the facility failed to provide care to promote dignity and respect for 1 of 8 residents reviewed (Resident #7). After Resident #7 turned on her call light to use the restroom, she waited so long she became incontinent of urine. Resident #7's felt terrible from becoming incontinent and not having assistance within 15 minutes to help her. Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #7's MDS included diagnoses of heart failure, hypertension (high blood pressure), renal disease (kidney), diabetes mellitus, depression, and morbid obesity. The MDS identified Resident #7 as occasionally incontinent of urine. A facility form titled Grievance Form 2/26/24 revealed Resident #7's husband reported a concern to Administration related to long call lights, resulting in Resident #7 urinating on herself. The form…

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 notify the Physician and family when a resident had a change of condition for 1 of 6 residents reviewed (Resident #1). Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score was a 2, indicating severe cognitive impairment. Resident #1's MDS included diagnoses of anxiety disorder, anemia, pancreatic cancer, hypertension (high blood pressure), heart failure and kidney disease. The Health Status Note dated 12/2/23 at 1:30 PM reflected when the aides helped Resident #1 up they observed a skin tear to her left outer shin. The nurse cleansed the area, applied steri strips, and covered it with a duoderm (waterproof dressing). Resident #1 couldn't tell the staff how the area occurred. Resident #1 had no complaints of pain or discomfort. The Clinical record lacked notification to the Physician or family regarding Resident #1's skin tear on her left…

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 interviews, staff interview, and facility record reviews, the facility failed to provide sufficient staff to meet the needs of the residents who resided in the facility for 3 of 8 residents reviewed (Residents #6, #7, and #8). Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Clinical Census revealed Resident #7 resided in room [ROOM NUMBER]-B. A facility form titled Grievance Form 2/26/24 revealed Resident #7's husband reported a concern to Administration related to long call lights, resulting in Resident #7 urinating on herself. The form documented the incident occurred over the weekend of 2/24/24 -2/25/24. The section of the form titled Pertinent Findings documented Resident #7 did have a 25-minute, 34 minute and 38-minute call light. The form listed Resident #7's grievance as confirmed. On 3/12/24 at 1:10 PM, Resident #7 reported things…

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 and staff interviews the facility failed to maintain a clean homelike environment. Due to maintenance concerns, the facility had missing tiles in some hallways. In addition, the facility lacked housekeeping at one time, resulting in dirty floors around toilets in some rooms. The facility reported a census of 43 residents. Findings include: On 8/7/23 at 7:30 AM observed a missing ceiling tile in the 100 and the 200 hallways. On 8/7/23 at 8:15 AM saw the floor around and behind the toilets in rooms [ROOM NUMBERS]. The floor appeared very dirty and grimy with dark stains. On 8/7/23 at 10:00 AM, Resident #3's family member reported that the facility had a bad temperature in the building for a couple of days when the air conditioning went gone out in the 200 hallway. She said that Resident #3 did get a fan to put in the room. On 8/7/23 at 9:17 AM, the Maintenance Manager (MM) explained that they removed the tile out of the ceiling at the end of the 200 hallway due to the air conditioning unit…

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

Based on observations, interviews, and policy review the facility failed to implement infection control procedures to prevent the spread of pathogens during food service and in the kitchen area. The facility reported a census of 43 residents. Findings include: On 8/7/23 at 11:27 AM observed a large floor fan in the doorway of the kitchen blowing across the room from the floor. The fan had dust accumulation on the blades. On the wall another fan hanged rotating and blowing across the room. The fan appeared very dusty and blowing in the direction of food. The ceiling had areas above the food prep table with accumulated dust. On 8/7/23 at 11:45 PM, watched as the Dietary Manager (DM) made Rueben sandwiches while wearing disposable gloves. The DM touched several surfaces with gloved hands and then touched the sandwiches with the same gloves. On 8/7/23 at 1:03 PM, the DM said that maintenance cleaned the ceilings but she never seen it being cleaned. On 8/16/23 at 9:10 AM, the DM acknowledged that she should have changed her gloves after touching surfaces and before touching the bread.…

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 the facility failed to notify the physician when a resident had a change in condition for two of three resident reviewed (Residents #9 and #2). Findings include: 1. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] reflected an admission date of 4/19/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive deficit. He required extensive assistance from one person for transfers, walking, and locomotion. In addition, he required supervision with set up assistance for eating. Resident #9 ate a mechanically altered diet. The Care Plan Focus initiated 4/18/23 indicated that Resident #9 had an activities of daily living (ADLs) deficit due to altered mobility and an intellectually disability. The Care Plan Focus initiated 4/18/23 reflected that Resident #9 had the potential for an altered nutritional status due to his diagnoses of Alzheimer's, Down Syndrome (a genetic disorder caused…

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 residents' record review, facility documents review, personnel record review, resident and staff interviews, the facility failed implement safeguards to prevent misappropriation of resident funds for 1 of 3 residents reviewed (Resident #10). After Resident #10 discharged from the facility she discovered the bank cashed a check written out to a staff member. Once Resident #10 learned of the cashed check, she reported the concern to the facility. Findings include: The admission Agreement signed by Resident #10 on instructed that the facility could not have complete control over residents' personal effect's and therefore the facility should not be responsible for loss or damage not occasioned by the negligence of the facility. Resident #10's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The Interview for Daily Preferences indicated that Resident #10 felt it is very important for her to care for her personal…

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, the facility failed follow the physician's order for one of three residents reviewed (Resident #2). The facility failed to contact the doctor when Resident #2 had an order to notify the physician when Resident #2 had a weight gain of 4-5 pounds in a 24-hour timeframe. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required extensive assistance from one person for transfers, dressing, and toilet use. Resident #2 had shortness of breath with exertion (movement) and when lying flat. He used a diuretic (medication remove excess fluid from the body) seven out of seven days in the lookback period. The MDS listed that Resident #2 used oxygen and a non-invasive mechanical ventilator (BiPAP/CPAP - machines usually used to assist in breathing by pushing the oxygen into and sometimes out of the body) during the lookback period.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, hospital record reviews, and staff interviews, the facility failed to identify a change in condition for one of three residents (Resident #9) reviewed for assessment and intervention. When Resident #9 started to decline in his intake, the facility identify the decline until he appeared lethargic and started to have labored breathing. At this time, the nurse sent Resident #9 to the hospital, where they admitted him for pneumonia, dehydration, and elevated sodium levels. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] reflected an admission date of 4/19/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive deficit. He required extensive assistance from one person for transfers, walking, and locomotion. In addition, he required supervision with set up assistance for eating. Resident #9 ate a mechanically altered diet. The Care Plan Focus initiated 4/18/23 indicated that Resident #9 had an activities…

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.