Bethany Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility investigation file review, staff and resident interviews, and facility policy review the facility failed to report an allegation of abuse involving Resident #3 within 2 hours of the allegation. The facility reported a census of 86 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 1/16/2025 documented Resident #3 had a Brief Interview of Mental Status (MDS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she refused care for 1-3 days of the 7-day review period. The following diagnoses were listed for the resident: chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. The Care Plan Focus area with an initiation date of 1/15/2025 documented Resident #3 refused care such as medications at times. Staff were instructed to encourage the resident to take her medications as prescribed by her physician. Staff are to notify the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 7 residents reviewed (Resident #5 and Resident #6). The facility failed to revise the interventions for a resident who sustained falls and a resident who had a significant change. The facility reported a census of 86 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #5 scored 5/15 on the Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The document revealed diagnoses of heart failure, benign prostatic hyperplasia, and urinary tract infection (UTI) in the last 30 days. The document revealed the resident had an indwelling catheter and was always incontinent of bowel. The MDS indicated the resident received hospice care services. Observed on 3/7/2025 at 11:30 AM Resident #5 asleep in bed, catheter bag at foot of bed on the right side with a dignity bag over it, and the 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, facility investigation file review, staff interviews and facility policy review the facility failed to use professional standards while administering Resident #3's medications. The facility reported a census of 86 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 1/16/2025 documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she refused care for 1-3 days of the 7-day review period. The following diagnoses were listed for the resident: chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. The Care Plan Focus area with an initiation date of 1/15/2025 documented Resident #3 refused care such as medications at times. Staff were instructed to encourage the resident to take her medications as prescribed by her physician. Staff are to notify the physician/hospice provider. The following…

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 2. Resident #22's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. The MDS listed Resident #22 as dependent or required partial assistance for toileting hygiene, bathing, and lower body dressing. In addition, Resident #22 required supervision or touching assistance for personal hygiene. The MDS included diagnoses of polio (a viral infection that can lead to partial or full paralysis), lack of coordination, muscle weakness, abnormalities of gait and mobility. In an interview on 10/28/24 at 12:34 PM, Resident #22 reported it took staff 45 minutes to answer his call light that morning. Resident #22 stated, they didn't have enough help. Resident #22 explained it took staff 20 to 30 minutes to answer the call light. Resident #22 added, he urinated in his chair because it took so long. It pissed him off when he had to urinate in his own chair. The Care Plan Focus revised 2/13/22 indicated Resident #22 had a risk for injury from falls related to diagnoses of post-polio…

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

Based on the facility staff report and interviews the facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week. The facility census was 85. Findings include: The September 2024 and October 2024 Nurse Schedule reflected the scheduled RN called to quit on 9/21/22, then walked out on 9/22/24. The document didn't include any other scheduled RNs on those dates. In an interview on 10/30/24 at 2:15 PM the Staff Coordinator stated on 9/21/24 and 9/22/24 she didn't have the on call phone, but knew about the situation. The Staff Coordinator stated the scheduled RN called in sick on 9/21/24 after being at work less than 30 minutes. On 9/22/24 the RN walked into the facility, looked at the schedule, and walked out. The Staff Coordinator stated they didn't fill the position with a RN for the empty shifts. The Staff Coordinator reported during the weekends they had limited RNs on the schedule/available, during the work week the acting DON may cover the RN position if necessary. In an interview on 10/30/24 at 2:25 PM the Administrator 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 observation, staff interview, and facility policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 85 residents. Findings include: During an observation on 10/28/24 at 9:55 AM Staff H, Cook, completed modification of the entree to mechanical soft consistency. Staff H obtained cooked turkey measured prior to the modification. Without performing hand hygiene, Staff H donned (applied) a glove to the right hand. They said they would use the gloved hand for placement of the turkey in the processor while the left hand would run the food processor. Staff H picked up the turkey with the gloved hand and placed it in the food processor. Staff H then placed their gloved hand over top of the processor, while the left hand managed the controls of the processor. Staff H used the non gloved hand to pour the contents into the measuring cup while the gloved hand used a scraper and moved the contents into the measuring cup. Once completed with the scraper Staff H used their gloved hand to compact the…

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

Based on clinical record review and staff interviews the facility to notify the Long-Term Care (LTC) Ombudsman of a transfer to the hospital for 1 of 6 residents reviewed (Resident #26). The facility reported a census of 85 residents. Findings include: Resident #26's Clinical Census reflected she had an unpaid hospital leave from 6/2/24 - 6/10/24. Review of the facility document, Notice of Transfer Form to LTC Ombudsman, for the month of Jun 2024 lacked notice of Resident #26's hospitalization. During an interview on 10/29/24 at 2:25 PM the Director of Nursing (DON) stated Social Services typically handled the bed holds and notification to the LTC Ombudsman. She added the document would be in the chart. During an interview on 10/30/24 at 10:55 AM the Social Services Director stated Resident #26 didn't have a signed bed hold or notification to the LTC Ombudsman when she admitted to the hospital. During an interview on 10/30/24 at 11:00 AM the Administrator acknowledged the facility didn't do a bed hold or notify the LTC Ombudsman for Resident #26's hospitalization starting on 6/2/24.

Based on record review, staff interviews, and policy review the facility failed to offer the resident, the Resident's Representative, and/or the Power of Attorney (POA) of a bed hold for 1 of 6 residents reviewed (Resident #26). The facility reported a census of 85 residents. Findings include: Resident #26's Clinical Census reflected she had an unpaid hospital leave from 6/2/24 - 6/10/24. Resident #26's electronic and paper clinical record lacked a bed hold for the hospitalization from 6/2/24 - 6/10/24. During an interview on 10/29/24 at 2:25 PM the Director of Nursing (DON) stated Social Services typically handled the bed holds and notification to the LTC Ombudsman. She added the document would be in the chart. During an interview on 10/30/24 at 10:55 AM the Social Services Director stated Resident #26 didn't have a signed bed hold or notification to the LTC Ombudsman when she admitted to the hospital. During an interview on 10/30/24 at 11:00 AM the Administrator acknowledged the facility didn't do a bed hold or notify the LTC Ombudsman for Resident #26's hospitalization starting…

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 2. Resident #36's MDS assessment dated [DATE] identified a Staff Assessment for Mental Status indicating they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of anxiety disorder, psychotic disorder, and Parkinsonism. The Preadmission Screening and Resident Review (PASRR) Level I Screen Outcome, dated 11/6/20 listed a summary of findings as Resident #36 didn't show evidence of a serious mental illness or an intellectual or developmental disability(IDD) that required PASRR intervention. The document provided Resident #36 had a current diagnosis of anxiety disorder and received fluoxetine (antidepressant) 20 milligrams (mg) per (/) day. The document instructed to submit a new screen if changes occur or new information refutes the findings. Resident #36's Medical Diagnoses included the following diagnoses: a. 10/1/23: Parkinson's Disease. b. 10/1/22: unspecified dementia, unspecified severity, with other behavioral disturbance. c. 7/4/21: Unspecified psychosis not due…

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 address dementia care for 1 out of 3 residents reviewed (Resident #1). The facility reported a census of 85 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS included diagnoses of non Alzheimer's dementia, stroke, seizure disorder (epilepsy), dementia mild, without behavioral, psychotic or mood disturbance, and anxiety. Resident #1's Care Plan revised 10/21/24 lacked information regarding dementia care. The Comprehensive Care Plan policy revised 7/18/22 instructed care, treatment and services shall be planned to ensure they are individualized to the resident's needs. The facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals. Results 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 observation, facility policy review, and staff interview the facility failed to provide appropriate infection prevention practices when administering medications, providing personal care, catheter care, and wound care for 3 of 4 residents reviewed (Residents #1, #22 and #58). The facility reported a census of 85 residents. Findings include: 1. Resident #22's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #22's October 2024 Medication Administration Records (MAR) included physicians' orders for acetaminophen (pain medication), calcium (nutritional supplement), aspirin (used either for pain or blood clot prevention), multi vitamin (nutritional supplement), docusate sodium (stool softener), and vitamin D3 (nutritional supplement). On 10/30/24 at 8:03 AM witnessed Staff I, Registered Nurse (RN), removing the following medications for Resident #22: acetaminophen, calcium, aspirin, multi vitamin, docusate sodium, 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 clinical record review, staff interviews and facility policy review the facility failed to follow 1 of 3 resident's (Resident #1) care plan while repositioning her in bed. The facility reported a census of 84 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 6/11/24 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented she was frequently incontinent of bowel and had no falls since her admission/entry, reentry or prior assessment. The MDS listed the following diagnosis: spina bifida, seizure disorder, anxiety, opioid use, insomnia, and chronic pain syndrome. The Care Plan focus area with an initiation date of 6/13/2023 documented Resident #1 was at risk for decline in her activities of daily living (ADLs) related to her diagnoses of spina bifida and seizures. The care plan documented the following intervention with a revision date of 7/15/2024, the resident required total assistance of two staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, resident interviews, facility investigative files and facility policy review the facility failed to treat 5 of 5 residents (Resident #2, #5, #6, #7, and #8) with dignity and respect. The facility reported a census 85 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE], Resident #2 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented the following diagnoses: cancer, anemia, dementia, and depression. The Care Plan focus area with an initiation date of [DATE] documented he is at risk for decline with his activities of daily living (ADLs) related to dementia, cancer and osteoporosis. The care plan documented he required assistance with washing his back, feet and legs during baths. Review of a statement dated [DATE], completed by the Director of Nursing (DON), revealed she documented she interviewed…

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 interviews, staff interviews, facility investigative file review and facility policy review, the facility failed to transfer 2 of 3 residents (Resident #5 and #6) in a manner to prevent any accidents and hazards. Staff transferred Resident #5 using a mechanical lift and one staff member. Staff also attempted to transfer Resident #6 with one staff instead of two. The facility reported a census of 85 residents. Findings include: 1. According to the annual MDS assessment tool with a reference date of [DATE], Resident #5 had a BIMS score of 13. A BIMS score of 14 suggested no cognitive impairment. The MDS documented he used a wheelchair. The MDS listed the following diagnoses: chronic lymphocytic leukemia of b-cell, cancer, hyperlipidemia, thyroid disorder, sepsis, and sleep apnea. The Care Plan focus area with an initiation date of [DATE] documented the resident at risk for ADL decline due to his diagnoses of leukemia and heart disease. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health records review, facility policy review, and staff interview the facility failed to provide a professional standard of quality by not following physician orders for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 90 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status documented as the resident is rarely/never understood. The MDS also revealed a diagnosis of nondisplaced fracture of base of neck of right femur, and subsequent encounter for closed fracture with routine healing. Review of Resident #1's Medication Administration Record (MAR) revealed an order for Oxycodone tablet 5 mg take 1 tablet by mouth every 4 hours as needed with a max daily amount of 30 mg. The MAR revealed an Oxycodone 5 mg tablet was given on October 19 at 12:30 PM and again at 2:25 PM. Review of facility policy revised 4/1/23 titled Medication Administration revealed the following: -Staff to remove medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility record review, facility policy review, resident interview, and staff interview, the facility failed to answer call lights in a timely manner for 4 of 18 residents reviewed (Residents #50, #72, #10, and #195). The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #50 revealed a Brief Interview of Mental Status (BIMS) of 15 out of 15 which indicated intact cognition. The MDS revealed the resident had chronic kidney disease stage 3 and need for assistance with personal care. The MDS revealed the resident required extensive assistance of 2 staff with transfers and toileting; and required a pressure reducing device for chair and bed. In an interview on 8/14/23 at 4:28 PM, Resident #50 reported that 2 weeks ago, she was left sitting on the toilet for 50 minutes, she sat so long her bottom hurt since she had a pressure ulcer on her bottom at the time. The Care Plan intervention initiated 4/5/22 revealed:…

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 and staff interviews the facility failed to provide privacy during personal cares to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 87 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented a Brief Interview of Mental Status (BIMS) of 14 out of 15 indicating no cognitive impairment. The MDS documented the resident required extensive assist of two persons for transfers and toileting and extensive assist of one person for dressing. The MDS documented diagnoses to include mixed incontinence. On 8/16/23 at 9:18 AM during an observation of Resident #10's transfer from bed to wheelchair, Staff O Certified Nurse Aide (CNA) and Staff P CNA completed the Hoyer lift transfer and changed the resident's shirt without pulling the curtain for privacy. The resident was facing the window during cares. On 8/16/23 at 9:44 AM Resident #10 stated CNA's frequently did not close the curtain when 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 resident interview, staff interviews and document review the facility failed to ensure grievances were reported and followed through for 1 of 1 residents reviewed (Resident #195). Resident #195 reported to Staff T that a wallet was missing and no investigation was completed. The facility reported a census of 87 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #195 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. On 8/14/23 at 2:47 PM Resident #195 stated she had a wallet that was missing 8 or 9 months ago. Resident #195 stated she left the wallet on the arm of the chair. Resident #195 stated this occurred when she was in another room when she was contagious. Resident #195 stated she told the social worker about the missing wallet, waited about 3 weeks and the facility had not ever replaced it. On 8/17/23 at 8:23 AM Staff T stated Resident #195 was missing a denim wallet for a little over a week. Staff T stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, the facility failed to obtain a bed hold within 24 hours of a hospitalization for 3 of 5 residents reviewed (Resident #1,#52, and #65). The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #65 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of pneumonia, urinary tract infection (UTI), asthma (COPD, chronic obstructive pulmonary disease) or chronic lung disease, and calculus of gallbladder with acute cholecystitis without obstruction (gallbladder inflammation cause of gallbladder stones). Review of the MDS's revealed the resident was hospitalized on : a. 6/3/23 b. 6/19/23 c. 6/30/23 In an interview on 8/16/23 at 12:16 PM, the Administrator reported that she feels that the bed hold form signed by the resident at admission covers whether or not they want their bed held…

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 2. The annual MDS assessment dated [DATE] revealed Resident #52 had diagnoses of septicemia, diabetes, and right lower limb cellulitis. The MDS revealed the resident readmitted to the facility from the hospital on 6/2/23. The MDS documented the resident received antibiotics 6 of 7 days during the look-back period and received IV medication. Resident #52's Care Plan revised 6/26/23 revealed the resident at risk for COVID-19 related to multiple comorbidities. The goal included the resident will remain free of COVID-19 infection through the review target date 10/24/23. The Care Plan lacked information about the resident's current infection of septicemia and cellulitis, PICC line monitoring, care and use, and intravenous (IV) antibiotic use and monitoring. The hospital Discharge Documents dated 7/19/23 revealed an order for ceftriaxone (an antibiotic) 2 grams IV every 24 hours for discitis (inflammation and infection between the vertebra disc space). The Physician's Orders dated 7/5/23 revealed an order for the PICC…

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 adhere to professional standards of quality for assessing and diagnosing a resident with a new order for an antipsychotic medication for 1 of 1 resident reviewed (#39). The facility identified a census of 87 residents. Findings include: On 8/15/23 1:05 PM, Resident #39's Electronic Health Record (EHR) included diagnoses of depression and anxiety but no other mental health diagnoses nor behavioral conditions that affected the resident's interpersonal interactions. On 5/1/23, a new diagnosis of Schizophrenia was added to the resident's EHR. The resident's transfer order details dated 5/19/22 revealed the resident did not have a Schizophrenia diagnosis nor a prescribed antipsychotic medication. A faxed response document dated 3/18/23 included a schizophrenia diagnosis and an antipsychotic medication order from the physician. The Progress Notes revealed the resident had two episodes of agitation; one in late March 2023 and another in early…

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, and clinical record review the facility failed to provide proper positioning in a wheelchair of appropriate size for 1 of 1 resident reviewed (#53). The facility reported a census of 87. Findings include: Resident #53's admission Minimum Data Set (MDS) dated [DATE] included diagnoses of dementia without behavioral disturbances, hip fractures, other fractures and repeated falls. It also revealed the resident's Brief Interview for Mental Status (BIMS) score was not obtained due to the resident's severely limited cognitive function. The MDS documented the resident required extensive, two-person assistance with mobility, and transfers and was not ambulatory. The MDS documented the resident's balance with transfers as not steady and only able to stabilize with staff assistance. The MDS documented the resident had impaired range of motion on one side of her lower extremity and used a wheelchair. On 8/14/23 at 3:10 PM, observed Resident #53 at the nurses' station in a wheelchair, tilted back, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interviews, the facility failed to provide necessary treatment to prevent developing avoidable pressure ulcers for 1 of 2 resident reviewed (Resident #25). The facility reported a census of 87. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating severely impaired cognition. The MDS documented the resident dependent on two persons for transfers and required extensive assist of two persons for bed mobility, dressing, toileting and hygiene. The MDS documented the resident had frequent urine incontinence and always incontinent of bowel. The MDS included diagnoses of atrial fibrillation, hypertension, diabetes, hip fracture, other fracture, dementia and seizure disorder. The MDS documented the resident had a weight loss of 5 percent or more in the last month or loss of 10 percent or more in the last six months. The MDS also revealed the resident had no pressure ulcers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident interview, family interview, staff interviews, and facility policy review the facility failed to prevent unsupervised falls and failed to provide transfers with appropriate number of staff for 3 of 3 (Resident #1, #9, and #72) residents reviewed. The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating moderately impaired cognition. The MDS further reveals diagnosis of type 2 diabetes, mild cognitive impairment, acquired absence of unspecified leg below the knee. The Incident Report dated 6/17/22 revealed Resident #9 was observed laying in the grass in the courtyard. Resident #9 stated that nobody was at the desk so she let herself out of the facility into the courtyard. The report further revealed that Resident #9 had got her wheelchair caught in the mud and tipped out of her wheelchair. The Progress Notes for the resident…

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 interviews and staff interviews the facility failed to ensure a resident was not catheterized unless clinically necessary, failed to receive appropriate care to prevent urinary tract infections (UTI) when has a catheter and failed to provide incontinence care for 2 of 2 residents reviewed for catheters and incontinence (Resident #76 and #10). The facility reported a census of 87 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 had no catheter and had bowel and bladder incontinence. The MDS assessment dated [DATE] revealed the resident had diagnoses of overactive bladder and had an indwelling catheter. The quarterly MDS assessment dated [DATE] revealed the resident had diagnoses of urinary tract infection (UTI) in the past 30 days and an overactive bladder. The MDS documented the resident had an indwelling catheter. The Care Plan initiated 3/21/23 revealed the resident had an indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #84). The facility reported a census of 87 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #84 documented a Brief Interview of Mental Status (BIMS) of 8 out of 15 indicating no cognitive impairment. The MDS documented diagnosis of hypertensive heart and chronic kidney disease without heart failure with stage 5 chronic kidney disease or end stage renal disease, type 2 diabetes mellitus with other diabetic kidney complications, and end stage renal disease. The Care Plan for Resident #84 dated 8/1/23 documented the resident is at risk for complications of renal failure and required dialysis treatments. The care plan directed staff to monitor the access site for signs and symptoms of infection and bleeding, and to observe for edema,…

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 3. The MDS dated [DATE] for Resident #191 revealed a BIMS of 13out of 15 indicating intact cognition. The MDS further revealed diagnosis of diabetes mellitus, hemiplegia affecting left nondominant side, and pulmonary fibrosis. Review of the MAR dated July 2023 revealed an order for PEG-3350/KCL SOL/Sodium drink 2L of solution by mouth beginning at 4 PM. The MAR further revealed an order for PEG-3350/KCL SOL/Sodium finish drinking the remaining 2L by mouth at 8PM. The MAR revealed both orders had been signed off as completed by Staff G. Interview 8/16/2023 at 6:10 PM with Resident #191's family member stated solution was still sitting on the nightstand when she entered the facility and Resident #191 was still drinking the solution on the way to the appointment on 7/28/2023. Observation 8/16/2023 at 6:22 PM of image sent by Resident #191's family revealed left over PEG-3350/KCL SOL/Sodium from a picture taken 7/28/2023. This image revealed approximately 1 quarter of the solution remaining in a gallon container.…

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, Centers for Disease Control and Prevention (CDC), facility policy review, and staff interview the facility failed to perform hand hygiene during toileting and/or incontinence care for 2 of 8 residents reviewed (Resident #72 and #10). The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #72 revealed a Brief Interview of Mental Status Score (BIMS) of 15 out of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of hereditary and idiopathic neuropathy (nerve damage that can cause weakness, numbness and pain, usually in the hands and feet), hip pain, and low back pain. The MDS revealed the resident required extensive assistance of 2 persons with transfers and toileting. Observation on 8/14/23 at 1:20 PM of Staff C, Certified Nurse Assistant (CNA), did not perform hand hygiene prior to putting on gloves, Staff C then pulled down the resident's slacks and disposable brief 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.