Cedar Falls Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interviews, the facility failed to administer medication as prescribed by the physician for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, other psychoactive substance use, unspecified with mood disorder, and psychophysiologic insomnia.Resident #1's Medication Administration Record (MAR) for September 2025 and October 2025 documented Gabapentin (pain medication also used as an antianxiety medication) ordered for three times a day omitted from evening dose 9/18/25 thru 10/7/25. On 10/21/25 at 12:35 PM the Director of Nursing (DON) provided the pharmacy delivery records for Gabapentin since admission 0n 8/1/25. She reported she would look further into the discrepancy with the medication.Resident #1's…

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 record review, policy review, and staff interviews the facility failed to report within the required time frame an allegation of abuse to Iowa Department of Inspection and Appeals and Licensing (DIAL) for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 37 residents. Findings include: Review of the facility intake information reported to DIAL documented the facility reported Resident #1 had an allegation of missing money on 3/7/25 at 5:23 PM. The facility staff learned of the incident when Resident #1 reported it on 2/25/25. During an interview on 3/25/25 at 1:20 PM, the Social Service Designee reported Staff A, Certified Nurses' Aide (CNA), told her Resident #1 reported he had missing money on 2/25/25. The Social Services Designee reported it right away to the Director of Nursing (DON) during the morning meeting after they verified Resident #1 was missing $50. The Administrator instructed her to check Resident #1's room to make sure he didn't miss place it. The Social Services Designee reported back to the Administrator, they didn't find the money…

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 medical record, family, volunteer, resident, and staff interviews the facility failed to revise and implement interventions on the comprehensive Care Plan to include redirection for a resident with a known behavior of packing food into her mouth for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 39. Findings Include: Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 6, indicating severe cognitive impairment. The MDS included diagnoses of traumatic brain dysfunction (brain damage caused by an outside force), heart failure, hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin). The MDS documented no swallowing disorders. The Care Plan Focus initiated 7/7/22 reflected Resident #2 had activities of daily living (ADL) self-care performance deficit related to confusion and impaired balance. 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, policy review, and staff interview the facility failed to serve hot food at a temperature of at least 135 degrees Fahrenheit (F) for 1 of 1 test tray requested. The facility reported a census of 38 residents. Findings include: The facility provided a test tray on 12/10/24 at 12:06 PM. The food temperatures measured the following: a. The casserole temperature - 55 degrees Celsius (C) or 131 degrees F. b. The beans temperature - 47 degrees C or 116.6 degrees F. Staff C, Dietary, confirmed she took the temperatures in Celsius. She reported she didn't know what the expected temperature of the food should measure. During an interview on 12/10/24 at 1:01 PM, the Dietary Manager explained they should serve the hot food at a temperature of at least 154 degrees F. The facility policy titled Food Preparation and Service, last revised October 2017, directed the staff to maintain hot food temperatures above 135 degrees F.

Based on observation, policy review, and staff interview the facility failed to ensure all staff entering the kitchen had their hair contained in a hair net for 2 of 2 observations. The facility reported a census of 38 residents: Findings include: During an observation on 12/9/24 at 10:01 AM, Staff A, Certified Nurse Aide (CNA), without wearing a hairnet, entered the kitchen, walked in front of the steam table to the coffee machine, filled a cup and exited the kitchen. During an observation on 12/10/14 at 11:18 AM, Staff B, CNA, entered the kitchen. She put a hair net on the top of her head, without containing all of her hair. The hairnet didn't contain the hair on the sides and back of her head. She walked around the steam table, got some ice out of the ice machine, opened a refrigerator, took out a pitcher of what appeared to be iced tea, set the pitcher on the prep table, had the cook cover the pitcher with plastic wrap, and exited the kitchen. During an interview on 12/12/24 at 9:58 AM, the Dietary Manager explained she expected all staff entering the kitchen to wear a hair net.…

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, policy review, manufacturer's instructions for use and staff interviews, the facility failed to ensure a medication error rate of less than five percent when administering insulin to a diabetic resident via insulin pen for 2 of 2 residents sampled (Residents #8 and #32). The Facility reported a census of 38 residents. Findings include: 1. On 12/10/24 at 8:18 AM, observed Staff F, Registered Nurse (RN), review Resident #8's Electronic Medication Administration Record (EMAR). Resident #8's December 2024 EMAR listed the following physician orders: a. Tresiba (insulin) Flex Touch Subcutaneous Solution Pen injector 100 Units (U)/Milliliter (ML). Inject 20 units subcutaneously one time a day related to type 2 Diabetes Mellitus (DM) with unspecified complications. b. Fiasp (Insulin) Pen Fill Subcutaneous Solution Cartridge 100 U/ML. Inject 15 unit subcutaneously three times a day related to type 2 DM with unspecified complications. At 8:19 AM Staff F dialed the dose selector button on the Fiasp insulin pen to 15 units and the Tresiba insulin…

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, policy review, and staff interview the facility failed to adhere to infection control practices while administering medication. Observations of the nursing staff revealed they touched medication with their bare hands during medication administration for 2 of 4 residents observed for oral medication pass. The facility identified a census of 38 residents. Findings include: 1. During an observation on 12/10/24 at 7:42 AM Staff E, Certified Medication Aide (CMA), failed to perform hand hygiene prior to setting up Resident #13 morning medications after she went to the kitchen to get them a supplement. Staff E unlocked the medication cart, opened the drawer and obtained Resident #13's medication cards placing them on top of the medication cart. Staff E held each medication card in her left hand and punched the pill out the back of the card into her right hand, then placed the pill into the medication cup. Staff E continued to utilize this technique for setting up the following medications for Resident #13 in addition to administration of stock…

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 document review, policy review, and staff interviews, the facility failed to ensure door alarm checks and wander guard alarm checks were physically completed as documented to ensure the safety of facility residents including 2 of 2 residents sampled (Residents #3 & #7). The Facility identified a census of 35 residents. Finding include: 1. Resident #3 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating a severe cognitive loss. The MDS documented Resident #3 as independent in ambulation and bed/chair transfers. The MDS listed diagnoses of stroke with aphasia and Parkinson's Disease. Resident #3 Elopement Risk Assessment completed 9/04/24 showed a score of 2 indicating a low risk of elopement. 2. Resident #7 MDS assessment dated [DATE] showed a BIMS score of 6 out 15 indicating severe cognitive loss. The MDS documented Resident #7 with a diagnosis of traumatic brain dysfunction, independent in ambulation/transfer, and wandered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and family interview on 7/15/24 the facility failed to make the required notifications for residents for 2 of 5 residents reviewed (Residents #5 and #6). The facility failed have an updated condition report list to accurately notify the family/resident representative of an acute transfer and hospital admission for Resident #6. In addition, the facility failed to notify the physician when the facility didn't have medications to give Resident #5 the night of her admission to the facility. The facility identified a census of 35 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition. The MDS listed Resident #6 as independent for bed mobility and partial to moderate assistance for transfers. The MDS included diagnoses of traumatic subdural hematoma (injury to the brain) and a seizure disorder. A progress note dated 7/15/24 at 10:32 AM written by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review the facility failed to following medication administration protocols for a new admission resident to the facility. The facility failed to provide medications as ordered on admission for 1 of 4 residents reviewed (Resident #5). The facility reported a census of 35 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 6/27/24 from a short-term hospital. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of orthopedic aftercare, hypertension (high blood pressure), muscle weakness. and severe obesity. Resident #5's June 2024 Medication Administration Record (MAR) included the following orders dated 6/27/24: a. Clonazepam 0.25 milligrams (MG) daily for anxiety at HS (hour of sleep). - The documentation indicated the facility held the 6/27/24 and 6/28/24 doses. b. Famotidine 20 MG twice a day (BID) 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.

Based on observation and interviews, the facility failed to provide a safe and comfortable environment due to leaks in the ceiling in the hallway entering the main dining room and in the main dining room. The facility reported a census of 39 residents. Findings include: Observation 7/2/24 at 8:58 AM, revealed 5 garbage cans with turn sheets underneath them, 4 caution wet floor signs and water coming from the ceiling. The ceiling looked discolored with tears in the ceiling of the hallway entering the main dining room. Further observation revealed 3 garbage cans with turn sheets underneath them in a corner of the dining room with water in the garbage cans. This ceiling looked discolored with a tear. During an interview 7/2/24 at 9:06 AM, Staff A, Housekeeping Assistant, explained they saw water coming in from the ceiling in the hallway entering the main dining and inside the dining room, three times. Staff A further added they replaced the sheets under the garbage cans when they get too wet. During an interview 7/2/24 at 9:20 AM, Staff B, Certified Medication Assistant (CMA), reported…

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 services that met professional standards regarding the administration of medications administered outside the scheduled time frames for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 39 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 4/19/24. The MDS identified and had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnoses including post-traumatic stress disorder (PTSD), psychotic disorder and chronic pain. Review of undated facility form titled, Medication Administration Times, identified the following administration times: a. AM: 6:30am 11:00am b. Lunch: 11:00am 2:00pm c. PM: 4:00pm 6:30pm d. Bedtime: 7:00pm 11:00pm The Medication Administration policy, revised 2/27/20, instructed to administer medications by following the principles 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 interviews and record reviews, the facility failed to provide or offer a shower twice a week for 1 of 3 residents reviewed (Resident #3). In addition, the facility failed to provide incontinence care for 3 of 3 residents reviewed (Residents #3, #4, #6). The facility reported a census of 39 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] reflected showers as very important to them. The MDS listed Resident #3 as occasionally incontinent. The MDS included diagnoses of cerebral vascular accident (CVA or stroke) and hemiplegia (paralysis that affects one side of the body). The Care Plan Focus initiated 4/3/24 indicated Resident #3 needed assistance with activities of daily living related to a history of CVA. The Goal listed to maintain his hygiene and appearance. Resident #3's Shower Sheets from 4/10/24 to 5/22/24 identified the staff didn't offer or provide him a shower from 4/13/24 to 4/20/24 and from 5/4/24 to 5/15/24. Resident #3's June 2024 Documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and policy review the facility failed to assist 1 of 1 residents reviewed with requested discharge planning to an assisted level of care (Resident #28). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #28 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. A Care Plan with a revision date of 1/26/23, documented that this resident was independent with bed mobility, personal hygiene/oral care (needs cueing in morning to wash face and brush teeth), dressing, eating, transfers, locomotion, and toilet use. The Care Plan stated this resident was an assist of 1 with bathing. On 2/19/24 at 1:52 p.m., Resident #28 stated that he wanted to go to an AL facility but they are taking so long. Resident #28 stated that the facility told him they have an assessment lined up. Resident #28 stated that it had been over 3 months ago and he still hadn't had 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 interview, record review, and policy review, the facility failed to notify the resident or their representative of the policy for Bed Holds for 1 of 3 resident reviewed (Resident #3). Resident #3 went out to the hospital on 2 separate occasion and no notification of the Bed Hold policy was issued for Resident #3. The facility reported a census of 35 residents. Findings include: A Census page for Resident #3, documented that this resident discharged to the hospital on 5/13/23 with a return date of 5/17/23 and discharged to the hospital again on 1/11/24 with a return date of 1/16/24. In an email dated 2/21/24 at 2:29 p.m., the Licensed Nursing Home Administrator responded that she was not able to find the Bed Hold notices for the above hospital discharges for Resident #3.

Based on record review and interview, the facility failed to do a PASARR (pre-admission screening and resident review) Level 2 for 1 of 3 residents reviewed (Resident #19). The facility failed to do a PASARR Level 2 when a mental health diagnosis was added for Resident #19. The facility reported a census of 35 residents. Findings include: A Diagnoses Page for Resident #19 documented a diagnosis of Post Traumatic Stress Disorder (PTSD) was added on 7/21/20. Resident #1 had PASARR Level 1 done on 1/10/22 and on 12/16/22. Post Traumatic Stress Disorder was not listed as a diagnosis on these PASARR Level 1 assessments and no PASARR 2 was done. On 2/21/24 at 2:23 PM, the Social Services Designee stated she did not do a Level 2 for this resident as his Level 1 documented a Level 2 was not needed. She acknowledged a change in status PASARR should have been done when the PTSD diagnosis was added. She asked when the diagnosis was added. When told it was added on 7/21/20 per the electronic health record, she stated she was not in the SSD position at that time.

Based on record review, staff interviews, and policy review the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for reevaluation when 1 of 2 residents reviewed (Resident #8) demonstrated increased behavioral, psychiatric, or mood-related symptoms and the facility received an order to send to the emergency room (ER) for Psychiatric evaluation and treatment. The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated 11/6/23 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented behaviors over the past week on 1-3 days she had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS…

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

Based on record review, resident, staff, and Provider interviews, and policy review the facility failed to provide adequate assessment and intervention to 1 of 2 residents reviewed for hospitalizations (Resident #16). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) for Resident #16 dated 12/15/2023, documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairments. The MDS documented he was dependent on staff for using the bathroom, shower/bathing, dressing, and rolling in bed. The MDS also instructed the facility did not attempt due to his medical condition or safety concerns him moving from a lying position to a sitting, standing, and walking. The MDS informed he is not on a urinary toileting program and is always incontinent of urine and bowel. The MDS documented diagnoses of renal failure, hip fracture, depression, and anxiety. Record review of Resident #16 Progress Note dated 1/9/24 at 4:03 AM documented Resident #16 informed staff that when he urinates he had pain that feels like broken glass…

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, resident, staff, and Provider interview, and policy review the facility failed to maintain records and complete routine assessments for 2 of 3 residents documented with pressure ulcers (Resident #17 and #24). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #17, dated 1/31/2024 documented a Brief Interview for Mental Status (BIMS) of 3, indicating severely impaired cognition. The MDS instructed she was dependent on staff for toileting, dressing, and bed mobility. The MDS documented diagnoses of anemia, neurogenic bladder, seizure disorder, bipolar disorder, and schizophrenia. The MDS documented she had one (1) Stage II (2) pressure ulcer. The MDS for Resident #17, dated 11/29/23 documented she had no pressure ulcers. Record review of Resident #17 Assessments in the facilities Electronic Health Record (EHR) documented inconsistent records of skin assessments for the following dates: a. 11/2/23 - Right Buttock, Unstageable 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 record review, staff interviews, and policy review the facility failed to maintain records for 1 of 5 residents reviewed (Resident #35) on education and offering of Pneumococcal and Influenza vaccination. The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #35 documented a Brief Interview for Mental Status (BIMS) of 3 indicating he had severely impaired cognition. Record review of Resident #35 Immunizations in the facilities Electronic Health Record on 2/21/2024 revealed he had not had the Influenza and Pneumococcal vaccine. Record review of Resident #35 Progress Notes on 2/22/24 lacked documentation he or his representative was provided with education and requested/refused Influenza and Pneumococcal vaccines. During an interview with the Director of Nursing (DON) on 2/21/24 at 1:24 PM revealed the facilities Social Worker obtains consents for residents on immunizations. During an interview on 2/21/24 at 2:21 PM with the facilities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to maintain records for 1 of 5 residents reviewed (Resident #35) on education and offering of COVID-19 vaccination. The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #35 documented a Brief Interview for Mental Status (BIMS) score of 3 indicating he had severely impaired cognition. Record review of Resident #35 Immunizations in the facilities Electronic Health Record on 2/21/2024 revealed he had not had the COVID-19 immunizations. Record review of Resident #35 Progress Notes on 2/22/24 lacked documentation he or his representative was provided with education and requested/refused COVID-19 immunizations. During an interview with the Director of Nursing (DON) on 2/21/24 at 1:24 PM revealed the facilities Social Worker obtains consents for residents on immunizations. During an interview on 2/21/24 at 2:21 PM with the facilities Social Worker revealed she does not have…

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, family and staff interview, and facility policy review the facility failed to provide adequate assessment and timely intervention for 1 of 3 residents reviewed (Resident #3). On 8/14/23 Resident #3 had a witnessed fall, was lowered to the floor by staff. Facility staff failed to assess the resident prior to assisting to stand, failed to report the fall to the charge nurse, and failed to provide ongoing monitoring and assessment following the fall. On 8/18/23 the resident was noted to have swelling, and yellow-green bruising to the left knee, required transfer and admission to the local hospital for a fractured left femur. The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 5/29/23 for Resident #3 identified moderately impaired cognitive skills for decision making. The MDS further revealed the resident required the limited assistance of one staff for transfers, and diagnosis that included Trisomy 18, aphasia (trouble speaking and understanding others), pain in the 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.