Accura Healthcare of Creston

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident interview, staff interviews, and policy review, the facility failed to fully review and revise the comprehensive care plan for 4 of 15 resident reviewed (#11, #12, #26, and #34). The facility reported a census of 30. Findings include: 1. An observation on 7/08/24 at 3:25 PM revealed Resident #26's legs and feet were swollen. The resident stated she was taking a water pill (diuretic) for a while for the swelling in her legs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hypertension, deep vein thrombosis (DVT; deep vein blood clot), hyperlipidemia (high cholesterol in the blood), diabetes mellitus, and morbid obesity. It revealed the resident was independent with eating and oral hygiene, required maximum assistance with upper body dressing, and was dependent in all other activities 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, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination by staff failing to perform appropriate hand hygiene during resident cares, medication administration, and meal service for 5 of 5 residents (Resident #3, #6, #12, #16, and #26) reviewed for infection control. The facility also failed to ensure resident equipment was sanitized after use for 2 of 2 residents (Resident #6 and #12). The facility reported a census of 30 residents. Findings include: 1. An observation on 7/08/24 at 1:18 PM revealed Resident #3's indwelling catheter tubing had a dependent loop with clear, yellow urine and sediment in it. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severely impaired cognition. It included diagnoses of neurogenic bladder (nerves that control the bladder do not function), epilepsy,…

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

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement required training for multiple topics for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in communication, Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and behavioral health. The facility lacked documentation that Staff J completed training in resident rights and infection control. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via…

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

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement communication training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in communication. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement resident rights training for 1 of 5 staff reviewed (Staff J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire date: Staff J 3/28/23. The facility lacked documentation that Staff J completed training in resident rights. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement Quality Assurance and Performance Improvement (QAPI) training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in QAPI. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement infection control training for 1 of 5 staff reviewed (Staff J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff J 3/28/23. The facility lacked documentation that Staff J completed training in infection control. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement compliance and eithics training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in Compliance and Ethics. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement behavioral health training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in Behavioral Health. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on clinical record review, policy review, and staff interview, the facility failed to document whether or not a resident wished to appeal the decision of skilled services ending for 1 of 3 residents reviewed who discharged from skilled services(Resident #234). The facility reported a census of 30 residents. Findings include: a. A 2/1/24 Notice of Medicare Non-coverage(NOMNOC) documented the facility informed Resident #234 that her skilled services would end on 2/1/24. The facility lacked documentation they informed the resident of the reason her services would end and lacked documentation regarding whether the resident wished to appeal the decision of the services ending. b. A 3/18/24 NOMNOC documented the facility informed Resident #234 that her skilled services would end on 3/20/24. The facility lacked documentation they informed the resident of the reason her services would end and lacked documentation regarding whether the resident wished to appeal the decision of the services ending. The facility Social Services Manual, dated 2/2015, stated the facility would provide a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review, the facility failed to complete a Significant Change Minimum Data Sheet (MDS) within 14 days for a resident placed on hospice care for 1 of 1 residents (Resident #27) reviewed. The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed significant change in status assessment with completion of the MDS on 6/5/24. The Progress Notes dated 5/15/24 at 3:00 PM revealed the Social Worker (SW) stated resident #27 was admitted to hospice care. The Encounter Note dated 5/22/24 revealed the Nurse Practitioner (NP) stated resident #27 had been evaluated by hospice and admitted with diagnosis of cerebral atherosclerosis. On 7/11/24 at 4:04 PM the Regional Director of Nursing stated MDS Coordinators are remote. He stated any care plan areas that trigger on the Care Area Assessments (CAA) of a comprehensive MDS is the responsibility of the remote MDS Coordinator to care plan. Daily…

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, resident interview, direction from the Resident Assessment Instrument (RAI), and policy review, the facility failed to assure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 14 residents (#21) reviewed for Accuracy of Assessment. The facility reported a census of 30 residents. Findings include: On 7/08/24 at 12:08 PM, the Administrator stated the facility currently had one (1) resident who received hemodialysis (HD) treatments On 7/08/24 at 3:00 PM, the resident stated he had been dependent on hemodialysis (HD) for several years and received HD treatments every Monday, Wednesday, and Friday. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of congestive heart failure (CHF), chronic kidney disease (CKD), end-stage…

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 facility policy review, the facility failed to notify Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for mental diagnosis and medications (Resident #6). The facility reported census of 30 residents. Findings include: The PASRR dated 1/4/24 for Resident #6 was prior to admission to facility, 5/21/24. The PASRR revealed no mental diagnosis or medications listed. The Minimum Data Sheet (MDS) assessment dated [DATE] revealed Resident #6 admitted to the facility with the diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. Resident #6 admitted to facility with drug classifications of antipsychotic, antianxiety, and antidepressant. The Care Plan initiated on 6/5/24 reveals diagnosis of dementia, depression, anxiety, and psychoactive drug use. On 7/10/24 at 10:20 AM the Social worker (SW) revealed the only PASRR for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and policy review, the facility failed to implement a comprehensive care plan for 1 of 15 residents reviewed (#9). The facility reported a census of 30 residents. Findings include: On 7/09/24 at 9:06 AM, Staff I, Certified Nurse Aide (CNA) transferred Resident #9 from the bathroom to her wheelchair and from the wheelchair to her bed without a gait belt. She placed the resident's oxygen nasal cannula (NC - pronged tubing used for oxygen delivery through the nose) back on the resident. The resident's portable oxygen tank supply regulator was set on 2 Liters Per Minute (LPM) and the indicator registered in the red, refill zone. The resident's room concentrator was also set on 2 LPM. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not conducted and indicated the resident was rarely or never understood. It included diagnoses of heart failure (HF), chronic obstructive pulmonary disease (COPD),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family interviews, staff interview and hospital record review, the facility failed to perform complete and accurate assessments following a fall for 1 of 1 residents reviewed for falls (Resident #34). The facility reported a census of 30 residents. Findings include: The Minimum Data Set assessment of Resident #34, dated 5/27/24 identified a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The MDS documented the resident admitted to the facility on [DATE]. The Risk Management form dated 6/3/24 at 8:45 pm documented Resident #34 was observed on the floor beside her bed, lying on her stomach. It revealed documentation the resident stated she was self transferring to her bed and slid off the side of the bed. The form noted no injuries observed at the time of the incident or post incident. The Progress Notes for the resident documented the following: On 6/4/24 at 3:12 am nurse summoned to resident room earlier. Resident found on stomach…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review, observation, staff interviews, and facility policy review, the facility failed to provide an environment that is free from accidents/hazards for 2 of 5 residents reviewed for environmental hazards (Resident # 11, #9). The facility reported a census of 30 residents. Findings include: 1. The facility document titled 5 Day Investigation Summary documented information which included the following: Staff F, Registered Nurse, (RN) was walking down the east hall at 6:30 pm on 6/28/24 when she observed the door to Resident #11's room slightly ajar and saw a male in the room. Staff F, RN entered the room and observed it was hazy with an odor of marijuana present with Resident #11 and two additional residents. Staff F observed two vapes lying on Resident #11's chest as she was in her wheelchair. Staff F separated the residents and removed the vapes from the room. The Minimum Data Sheet (MDS) assessment dated [DATE] for Resident #11 identified a Brief Interview 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 clinical record review, observations, staff interview, and policy review the facility failed to follow infection prevention standards during incontinence cares for 2 of 2 residents review for incontinence cares (Residents #6, #12). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment of Resident #6 dated 6/5/24 reflected the resident to have short term and long term memory problems. The MDS revealed the resident totally dependent on toileting and personal hygiene. The MDS reflected the resident always frequently incontinent of urine and not rated for bowel incontinent. The Care Plan, last reviewed 6/3/24, identified the resident to be incontinent of bladder. The Care Plan directed staff to provide incontinence care after each incontinent episode. The Care Plan did not state bowel incontinence. On 7/9/24 at 1:28 PM, Staff L, Certified Nurse Aide (CNA) entered resident #6 room. Resident #6 in wheelchair. Staff M, Certified Nurse Aide (CNA), brought 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 provide oxygen per physician orders for 1 of 14 residents reviewed (#9). The facility reported a census of 30 residents. Findings include: On 7/09/24 at 9:06 AM, Staff I, Certified Nurse Aide (CNA) placed the resident's oxygen nasal cannula (NC - pronged tubing used for oxygen delivery through the nose) back on the resident. The resident's portable oxygen tank supply regulator was set on 2 Liters Per Minute (LPM) and the indicator registered in the red, refill zone. The resident's room concentrator was also set on 2 LPM. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted and indicated the resident was rarely or never understood. It included diagnoses of heart failure (HF), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and non-Alzheimer's dementia. It also indicated the resident used oxygen. 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 observations, clinical record review, staff interview and facility policy review the facility failed to administer medications at an error rate of under 5%. The facility reported a census of 30 residents. Findings include: The continuous observation of medication pass on 7/9/24, beginning at 7:35 am observed the following: Staff A, Registered Nurse (RN) passed medications to Resident #26. A total of 19 medications were observed being administered to Resident #26. The State Surveyor recorded each medication given to Resident #26 during the observation which included: - Furosemide, 10 mg, 2 tablets - Magnesium Oxide, 400 mg, 1 tablet - Fiber Lax, 625 mg, 1 capsule Staff A, RN next passed medications to Resident #3. A total of 8 medications were observed being administered to Resident #3. The State Surveyor again recorded each medication given to Resident #3 during observation which included: - Calcium, 500 mg, 1 tablet Following the observation of the medication pass, the list of administered medications were reconciled against the July 2024 Medication Administration Record…

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, family and provider interviews, and facility policy review, the facility failed to update and revise a resident care plan to reflect non compliance with physician orders for 1 of 4 (Resident #1) residents reviewed. The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) of Resident #1 dated 10/10/23 identified a Brief Interview of Mental Status (BIMS) score of 13 which indicated cognition intact. The MDS revealed the resident required supervision or touching assistance for bed mobility and transfers. The MDS documented diagnoses that included high blood pressure, renal failure, diabetes mellitus, anxiety, depression, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). The Comprehensive Care Plan of Resident #1, reviewed 10/17/23, identified a focus area of the resident having COPD. The care plan directed to give oxygen therapy as ordered by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, staff interviews and policy review, the facility failed to implement the abuse and neglect policy by not completing background checks appropriately prior to staff employment. The facility reported a census of 27 residents. Findings include: Review of a document titled, Employee List Report generated on 3/18/24 documented a hire date for Staff D of 1/14/24, Staff E of 1/14/24, and Staff F of 1/14/24. Review of the document titled Single Contact License and Background Check dated 1/25/24 for Staff D, Dietary Manager, documented results of further research needed in the criminal history check and submission of form [PHONE NUMBER] on the dependent adult abuse check. No subsequent research completed by the facility. Review of document titled Single Contact License and Background Check dated 1/26/24 for Staff E, Dietary Aide, documented results of further research needed in the criminal history check. No subsequent research completed by the facility. Review of document titled Single…

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, family interview and staff interview, the facility failed to treat each resident with dignity and respect for 1 of 3 residents reviewed (Resident #3) by not providing appropriate clothing when the resident was in a public area of the facility. The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) of Resident #3, dated 8/31/2023, indicated he had severe cognitive impairment for daily decision making. The MDS revealed the resident required extensive physical assistance of 2 people for bed mobility, transfer, walking, dressing and toileting. The MDS documented diagnoses that included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The MDS reflected no diagnoses of anxiety, depression, or any other psychiatric/mood disorders. The Care Plan of Resident #3 revealed a Focus Area of use of psychotropic medication related to vascular dementia, dated 8/28/2023. The Care Plan documented a goal of the resident remaining free of drug related…

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 follow physician orders for 2 of 3 residents reviewed (Resident #3, #5). The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #3, dated 8/31/2023, indicated Resident #3 had severe cognitive impairment for daily decision making. The MDS documented diagnoses that included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The MDS reflected no diagnoses of anxiety, depression, or any other psychiatric/mood disorders. The Care Plan of Resident #3 revealed a focus area of use of psychotropic medication related to vascular dementia, dated 8/28/2023. The Care Plan documented a goal of the resident remaining free of drug related complications including cognitive/behavioral impairment. The focus area of behavior problem, dated 8/31/2023 directed staff to intervene as necessary to protect the rights and safety 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, clinical record review, staff interview and policy review, the facility failed to keep complete and accurate resident records for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] of Resident #5 reflected an admission date to the facility of 10/31/2023. The MDS revealed the resident to be dependent for bed mobility of rolling left and right. The MDS documented a height of 60 inches and a weight of 95 pounds. The MDS documented the resident to be at risk of development of pressure ulcers, but no unhealed pressure ulcers present on admission. The MDS documented the resident had no venous or arterial ulcers and no other ulcers, wounds or skin problems present. The Care Plan of Resident #5 revealed a focus area of potential for pressure ulcer development, dated 11/13/2023. It directed staff to administer medications as ordered, administer treatments are ordered, document and report changes in skin…

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.