North Crest Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors on the care plan related to high risk medications in 3 out of 5 sampled residents reviewed (Resident #2, #13 and #37). The facility reported a census of 61 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of anxiety, dementia and Chronic Obstructive Pulmonary Disease (COPD). The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The Clinical Physician Orders for Resident #13 showed the following orders:a. Morphine (opioid medication) every two as needed for pain or shortness of breath with a start date of 3/25/25.b. Lorazepam (antipsychotic medication) every four hours for restlessness/anxiety as needed with a start date of 5/29/25. The Care Plan identified Resident #13 was prescribed high risk medications for anxiety and pain. 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 Record (EHR) review, staff interview, and facility policy, the facility failed to ensure bed hold notice was sent to the resident and or the resident's responsible person when the resident transferred out of the facility for 1 of 1 residents reviewed (Residents #60). The facility reported a census of 61 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #60 documented a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment. Review of Resident #60's EHR documented no bed hold Review of Resident #60's EHR dated 5/14/25 at 9:27 PM titled, Progress Notes documented Resident #60 was transferred to the hospital with shortness of breath and chest pain with pain to the jaw and neck. Progress Note documented Resident #60 could not speak related to discomfort and Resident #60 requested to be transferred to the hospital. Resident #60's EHR titled, Progress Notes documented the resident remained at the hospital 5/15/25 or 5/16/25.…

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, resident interview, staff interviews, record review and policy review the facility failed to obtain and follow physicians' orders for 2 of 21 of residents (Resident #36 and #6). Staff chose to hold insulin for Resident #36 without obtaining doctor-specified parameters on when to hold the insulin and failed to notify the doctor when the insulin hadn't been given. Resident #6 had an indwelling urinary catheter, staff failed to obtain an order for the device. The facility reported a census of 61 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He was independent with hygiene, toileting, dressing, transferring and walking. His diagnoses included: diabetes mellitus, renal insufficiency, schizophrenia, anxiety disorder and adult failure to thrive. The Care Plan updated on 5/1/25, showed that Resident #36 needed a therapeutic diet related to diagnosis of diabetes…

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, electronic medical record (EMR) reviews, staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed, requiring the use of oxygen (Resident #47). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) for Resident #47 dated 7/17/25 identified a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The MDS documented diagnoses that included: heart failure, hypertension, anxiety disorder, obstructive sleep apnea, and pulmonary hypertension. The document provided the resident utilized oxygen upon admission and while a resident, and that oxygen was continuous on admission.Resident #32's Care Plan dated 7/23/25 identified a focus area of oxygen therapy related to ineffective gas exchange. Interventions for staff included oxygen at 3-5 liters (L). The 7/25 Medication Administration Record (MAR)-Treatment Administration Order (TAR) did not provide orders or…

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, Electronic Medical Record (EMR) review, and policy review, the facility failed to provide appropriate treatment and services to meet a resident's highest practicable physical, mental, and psychosocial well-being for a resident diagnosed with dementia for 1 of 1 residents reviewed (Resident #37). The facility had a census of 61. Findings include:The Minimum Data Set (MDS) for Resident #37 dated 6/25/25 identified a BIMS score of 3/15 indicating severe cognitive impairment. The MDS included diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The document identified mood feelings of feeling down, depressed, or hopeless in 2-6 days in the last 2 weeks of the reporting period. The MDS identified Resident #37 took antipsychotic, antianxiety and antidepressant medications during the last 7 days of the assessment period.The 7/25 Medication/Treatment Administration Record (MAR-TAR) identified an order dated 10/14/24 for nursing to monitor every shift for target behaviors: (refusal of cares, yelling out, physical aggression…

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 ensure that staff obtained signed consents and were educated on the influenza immunization before it was administered. The facility reported a census of 61 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). His diagnoses included arthritis, non-Alzheimer's Dementia, anxiety disorder and cerebrovascular disease. The Care Plan for Resident #11, updated on 11/12/24, showed that her immune system had aged and staff were to encourage the resident to follow current guidelines for influenza and pneumonia vaccines. The tab titled: Vaccines, showed that Resident #11 received the Influenza vaccine on 10/3/24. The chart lacked a consent and documentation that education had been provided. 2) The MDS dated [DATE], indicated that Resident #7 had a BIMS score of 13 (moderate cognitive deficits). She was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and policy review the facility failed to ensure that staff obtained signed consents and were educated on the COVID-19 immunization before it was administered. The facility reported a census of 61 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). His diagnoses included arthritis, non-Alzheimer's Dementia, anxiety disorder and cerebrovascular disease. The Care Plan for Resident #11, updated on 11/12/24, showed that her immune system had aged and staff were to encourage the resident to follow current guidelines for COVID-19 vaccines. The tab titled: Vaccines, showed that Resident #11 received the COVID-19 vaccine on 10/3/24. The chart lacked a consent and documentation that education had been provided. 2) The MDS dated [DATE], indicated that Resident #7 had a BIMS score of 13 (moderate cognitive deficits). She was totally dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staffing reviews, interviews, and Facility Assessment review the facility failed to provide adequate nursing staff to assure residents safety and well-being. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #7 dated 7/23/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognition. Resident #7 on 9/16/24 at 1:09 PM stated call lights can take longer than 15 minutes to answer. The resident stated he would watch the clock to determine the length of time for answering. Staff C, Certified Nursing Assistant (CNA), on 9/18/24 at 1:05 PM stated working on the weekends was more difficult as there were less staff. Staff C stated due to the lower staffing on the weekends, and occasionally during the week, the staff could not answer the call lights as efficiently and resident cares could be affected. Review of Quarter 3 2024 (April, May, June) Scheduled Hours and Per Patient Date (PPD) data 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 observation, resident interview, staff interview, and policy review the facility failed to follow standard precautions while separating laundry, and following enhanced barrier precautions (EBP). The facility further failed to establish a facility wide written infection prevention control policy. The facility reported a census of 56 residents. Findings include: 1. Observation 9/17/24 at 11:17 AM Staff E revealed laundry is being separated without gloves and gowns. Staff E further revealed that laundry is separated, and then hand sanitizer is utilized. Gloves were noted around the corner from the washing machines on a shelf at this time. During this observation it was also noted there were no gowns in the laundry room. Interview 9/17/24 at 11:21 AM Staff E revealed that staff should be wearing gloves and gowns while separating laundry with the positive Covid-19 cases in the building. Interview 9/17/24 at 11:40 AM with the Director of Nursing (DON) revealed that gloves should be worn when separating…

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 obtain complete resident records to honor the resident wishes as stated on the Iowa Physician Order for Scope and Treatment. The facility failed to obtain a physician order for DNR for 1 of 14 residents (Resident #32) reviewed. The facility reported a census of 56 residents. Findings include: According to the documents, Code Status Form and and the Iowa Physician Orders for Scope of Treatment (IPOST), signed by Resident #32 on [DATE] and physician on [DATE], the resident indicated a do not resuscitate (DNR) with limited interventions, no artificial nutrition by tube, and transfer to the hospital. Review of Resident #32's Clinical Physician Orders in the electronic medical records, signed physician orders for 7/24 and 8/24, the facility failed to obtain a signed order for a DNR status. On [DATE] at 8:30 AM Staff A, Social Worker, confirmed Resident #32 had a DNR status and there was not a physician order in the electronic…

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, policy review, and staff interviews, the facility failed to notify the physician immediately after a sudden change in the resident's condition, and failed to notify the physician immediately after transferring a resident to the emergency department (ED) with chest pain and shortness of breath for of 1 of 16 resident reviewed (Resident #28). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #28 revealed diagnoses of heart failure, pulmonary hypertension, respiratory failure and stroke. The same MDS documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. In an interview on 9/16/24 at 10:34 AM, Resident #28 reported on 6/16/24 she transferred to the ED for a cough, sharp chest pain and shortness of breath. The Progress Note dated 6/16/2024 at 2:46 PM documented Resident #28 called the nurse into the room with complaints of sharp chest pain, shortness of breath,…

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 document review, staff interview, and policy review the facility failed to notify a resident 48 hours in advance when the end of a medicare part A stay or when all of part B therapies were ending to 1 of 3 residents (Resident #146) reviewed. The facility reported a census of 56 residents. Findings include: Review of Resident #146's Advanced Beneficiary Notice (ABN) revealed there was no ABN to review. Interview 9/18/24 at 2:34 PM with the Administrator revealed that he could not provide a ABN form for Resident #164, as the facility could not locate a copy of the form. The Administrator further revealed that ABN's should be given with proper notice to the resident. Follow up interview 9/19/24 at 10:41 AM with the Administrator revealed the facility does not have a policy, but does follow the federal regulations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 3 residents (Resident #1, #60) reviewed. The facility reported a census of 56 residents. Findings include: 1. Review of Resident #1's Electronic Health Record (EHR) page title progress notes revealed an entry dated 9/14/24 at 10:22 AM documenting that Resident #1 was sent to the emergency room for treatment of a laceration to the forehead after a fall. Review of bed hold notification for Residents #1 revealed there was no bed hold form to review. 2. Review of Resident #60's Minimum Data Set (MDS) dated [DATE] revealed a most recent admit date from an acute hospital stay dated 9/7/24. Review of Resident #60's Electronic Health Record (EHR) revealed hospitalization for Resident #60 from 8/31/24 through 9/3/24. On 9/18/24 at 12:55 PM the Administrator acknowledged the facility did not have a signed bed hold for the resident for the hospitalization. The Administrator stated the 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 electronic health record review (EHR) and staff interviews the facility failed to submit a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual assessment within the required timeframe for 1 out of 16 residents reviewed (Residents #216 ) reviewed. The facility census was 56. Findings include: The review of Resident #216's MDS assessment data indicated assessments dated 8/26/24 Entry, 8/29/24 Medicare - 5 Day, and 9/5/24 Entry lacked transmission dates and acceptance. MDS document 9/5/24 indicated the most recent admission date of 9/5/24. The review of the assessment data did not include a Discharge with Return Anticipated Assessment. On 9/18/24 at 12:45 PM Staff B, MDS Coordinator, acknowledged she was still fairly new in the position and was not sure if everything had to be submitted. The staff stated if the MDS page indicated completion of an assessment, that indicated the assessment was done, and if it indicated accepted that meant the assessment had been completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately recording medication use for 2 of 5 residents reviewed (Residents #7, and #31). The facility reported a census of 56 residents. Findings include: 1. Review of Resident #7's MDS dated [DATE] revealed diagnosis of cancer, and stroke. The MDS further revealed Resident #7 received anticoagulant medications 7 out of the 7 days during the look back period. Review of Resident #7's Electronic Health Record (EHR) page titled Physician's Orders revealed that Resident #7 did not have any order for anticoagulant medications. 2. Review of Resident #31's MDS dated [DATE] revealed diagnosis of traumatic brain dysfunction, non-Alzheimer's dementia, anxiety disorder, and psychotic disorder. The MDS further revealed Resident #31 received hypnotic medication, and antianxiety medications 7 out of the 7 days…

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 document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for anticoagulants for 2 of 5 residents (Residents #17, and #31) reviewed. The facility reported a census of 56 residents. Findings include: 1. Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed anticoagulant medication usage for 7 of the 7 day look back period. Review of Resident #17's Electronic Health Record (EHR) page titled Physician's orders revealed an order for Eliquis 5mg tab take 1 tablet by mouth twice daily. Review of Resident #17's Care Plan with a review date of 8/23/24 revealed no documentation of anticoagulant medication use or interventions to direct staff on bleeding and/or bruising. 2. Review of Resident #31's MDS dated [DATE] revealed anticoagulant medication usage for 7 of the 7 day look back period. Review of Resident #31's EHR page titled Physician's orders revealed an order for Eliquis…

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 professional standards of care by not obtaining daily weights per physician orders for 1 of 16 residents reviewed (Resident #56). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #56 revealed diagnoses of atrial fibrillation, coronary artery disease, heart failure, and renal insufficiency. The same MDS documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Review of Resident #56's Care Plan revealed the resident at risk for weight variations related to history of diuretic use. Diagnosis of heart failure and elevated cardiac labs. Review of Resident #56's written Physician Orders dated 7/25/24 revealed an order for daily weights. Review of Resident #56's written Physician Orders dated 7/30/24 revealed an order for daily weights. The Weight and Vital Report for Resident #56 showed the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility document review and staff interviews, the facility failed to ensure implemented interventions to reduce hazards and protect residents were followed for 3 of 3 residents (#1, #2 #3) reviewed. The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment of Resident #1 dated 7/5/24 reflected the Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility/transfers, dressing, hygiene, and toileting. The resident used a walker and wheelchair. Resident #1 hand an indwelling catheter and had occasional bowel incontinence. Resident #1's Care Plan revealed an intervention dated 7/1/24 directing staff the resident transferred with assistance of 2 staff with a gait belt and walker. Fall interventions for staff to use dated 7/1/24 the resident required the call light within reach, use the call light and prompt response for all…

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, family interview, clinical record review, facility document review and staff interviews, the facility failed to provide nursing staff to meet the needs of the residents by not responding to call lights in a timely manner for 2 of 3 residents (Resident #1 and Resident #2) reviewed. The facility reported a census of 54. Findings include: 1. The Minimum Data Set (MDS) assessment of Resident #1 dated 7/5/24 reflected the Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility/transfers, dressing, hygiene, and toileting. The resident used a walker and wheelchair. Resident #1 had an indwelling catheter and had occasional bowel incontinence. On 8/5/24 at 1:40 PM a family member indicated the resident would have call lights that could range from 25-35 minutes in length before being answered. The family member stated a staff member said on one occurrence it had taken a while to answer the…

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

Based on observation, clinical record review, staff interviews, and facility policy review, the facility staff failed to maintain infection control practices by failed to wash hands during personal care for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #3 dated 6/11/24 reflected the Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The resident was dependent on staff for toileting hygiene and clothing management. The resident was always incontinent of bladder and bowel. The Care Plan provided staff with interventions for toileting, bed mobility, hygiene and transfers. Resident #3 required 1-2 staff for toileting, bed mobility, and hygiene. Transfers were completed with the use of 2 staff and a full body lift (Hoyer Lift). Continuous observation on 8/2/24 at 12:12 PM revealed Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA, complete personal hygiene and transfer with Resident #3. Upon entry into Resident #3's bedroom…

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, family interviews and facility policy the facility failed to notify 2 of 3 resident's (Resident #1 and #2) family when they sustained a fall. The facility reported a census of 53 residents. Findings include: 1) The annual Minimum Data Set (MDS) assessment tool with a reference date of 6/26/23, documented Resident #1 had a Brief Interview of Mental Status (MDS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented he required limited assistance of one staff for bed mobility, transfers, locomotion on the unit, dressing and personal hygiene. The MDS documented the following diagnoses: chronic obstructive pulmonary disease (COPD), anemia, obstructive uropathy, malnutrition, depression and urine retention. The care plan focus area with an initiated date of 8/8/2023 documented the resident at increased risk for falls because of his limited mobility. On 8/3/2023 the care plan directed staff to use his wheelchair while assisting him to the bathroom. The following Progress Note documented: a) On 8/3/23 at 5:38…

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 failed to complete an assessment prior to hospitalization and upon return fromt the hospital for 1 of 3 residents (Resident #5) reviewed. The facility reported a census 53 residents. Findings included: The admission Minimum Data Set (MDS) assessment tool with a reference date of 3/1/24 documented Resident #5 had a Brief Interview Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented the following diagnoses: stroke, atrial fibrillation, heart failure, renal failure, pneumonia, thyroid disease, depression, obesity, and fibromyalgia. The following Progress Notes documented: a) On 3/12/24 at 11:45 AM respiratory wheezing to bilateral lungs, a nebulizer treatment given as ordered with some improvement in lung sounds. Resident #5's physician notified and received an order for a chest x-ray, to be done stat (as soon as possible). b) On 3/13/24 at 1:02 AM Resident #5 remains on monitoring due to upper respiratory infection. Resident has harsh, loose cough, oxygen…

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, staff interviews and policy review the facility failed to complete routine hand hygiene and failed to use a sanitized oral syringe for medication administration for 1 out of 1 residents reviewed (Resident #9). The facility also failed to complete hand hygiene after administration of eye drops for 5 of 5 residents reviewed (Resident #14, #41, #22, and #17). The facility reported a census of 57 residents. Findings include: On 6/7/23 at 9:29 AM observations revealed the following: a. Staff B, Certified Medical Assistant (CMA), prepared to administer liquid Morphine to Resident #9 by retrieving an oral syringe from the Morphine storage box. Staff B then placed the oral syringe directly on top of the medication cart without placing the oral syringe on top of a sanitized area to prevent the possible spread of infection. Staff B opened the bottle of liquid Morphine, placed the unsanitized oral syringe down into the liquid medication, and withdrew 0.5 ML of liquid Morphine. Staff B entered Resident #9's room, administered the Morphine, then…

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 and submit a comprehensive assessment related to a significant change for 1 of 5 residents reviewed (Resident #29). The facility reported a census of 57 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] for Resident #29 documented a Brief Interview of Mental Status (BIMS) of 10 out of 15 possible points indicating moderate cognitive impairment. The MDS documented the resident required supervision with transfers, walking, locomotion and toileting and was independent with eating. The hospital Discharge Instructions dated 3/15/23 revealed diagnoses to include closed intertrochanter fracture of left hip. The Instructions documented orders for Resident #29 to return to a skilled level of care and receive physical and occupational therapy. The 5-day scheduled MDS assessment dated [DATE] for Resident #29 documented a BIMS of 15 out of 15 possible points indicating no cognitive impairment. The MDS revealed 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.