Ridgecrest Village

Based on interview, clinical record review, and facility policy review the facility failed to ensure timely completion of an admission Minimum Data Set (MDS) assessments for one of two residents reviewed for Resident Assessment Task (Resident #38). The facility reported a census of 51 residents. Findings include: Review of Resident #38's Electronic Health Record (EHR) revealed the resident admitted to the facility 1/16/24. Review of the resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date 1/23/24 revealed the assessment completed on 2/16/24. On 9/26/24 at 10:30 AM, the MDS Coordinator confirmed the assessment was late. On 9/25/24 at 3:02 PM, a Facility Policy to address MDS completion requested. On 9/25/24 at 4:07 PM, the Administrator explained the facility did not have a policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for two of two residents reviewed for Resident Assessment Task (Resident #13, Resident #38). The facility reported a census of 51 residents. Findings include: 1. Review of Resident #13's Quarterly MDS assessment with Assessment Reference Date (ARD) 6/25/24 completed on 7/11/24. 2. Review of Resident #38's Quarterly MDS assessment with ARD 4/23/24 completed on 5/9/24. On 9/26/24 at approximately 10:30 AM, the MDS Coordinator queried if there were issues completing quarterly assessments timely. Per the MDS Coordinator, it was pipped (part of Performance Improvement Project) for QAPI (Quality Assurance Performance Improvement). When queried about the specific MDS above, the MDS Coordinator explained for MDS 4/23/24 was waiting on other people to do their section, and for the MDS dated [DATE] MDS Coordinator had other matters she was attending to and there was not 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.

Based on clinical record review and staff interview the facility failed to ensure Minimum Data Set assessments submitted timely for one of two residents reviewed for Resident Assessment Task (Resident #13). The facility reported a census of 51 residents. Findings include: Review of Resident #13's Quarterly MDS assessment with Assessment Reference Date (ARD) 4/2/24 was completed 4/16/24. The assessment was submitted 5/16/24. On 9/26/24 at approximately 10:30 AM the MDS Coordinator explained they submitted every other week on Friday. When queried about Resident #13's MDS, the MDS Coordinator acknowledged it was late. A Facility Policy to address submitting MDS requested via email to the facility's Administrator. On 4/26/24 at 1:25 PM, the Administrator explained via email the facility did not have a policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) assessment for one of five residents reviewed for unnecessary medications (Resident #23). The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took antianxiety, anticoagulant, opioid, and antiplatelet medication. Review of the resident's Medication Administration Record (MAR) dated August 2024 revealed the resident only took anticoagulant medication from the medication classes listed above. On 9/26/24 at 10:59 AM, the MDS Coordinator explained she looked at the wrong person, and acknowledged that was why the mistake occurred. On 9/25/24 at 3:02 PM, a Facility Policy to address MDS accuracy requested. On 9/25/24 at 4:07 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interview, the facility failed to complete a Baseline Care Plan within 48 hours of admission for 2 of 2 newly admitted residents reviewed (Resident #32 and Resident #53). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The MDS listed diagnoses included: acute chronic systolic heart failure (commonly called congestive heart failure), type 2 diabetes mellitus with unspecified complications. The MDS documented Resident #32 was admitted on [DATE]. A review of the Clinical admission Assessment, dated 8/19/24, revealed the Care Planning section did not identify Focus Areas, Goals or Interventions for the risk factors, diagnoses or care needs for Resident # 32. During an interview on 9/25/24 10:22 AM, the MDS Coordinator reported she does not complete the Baseline Care Plans and these should…

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 interview and record review the facility failed to update the resident's Care Plan following discontinuation of anticoagulant medication for one of seventeen residents reviewed for care plans (Resident #19). The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. Per this assessment, the resident did not take anticoagulant medication. On 9/24/24, review of the resident's Care Plan, revised date 7/18/23, revealed the resident is on anticoagulant therapy; Coumadin (brand name of blood thinner medication, commonly known as warfarin.) Review of Resident #19's Physician Orders for revealed Coumadin discontinued on 5/9/24. On 9/26/24 at 10:43 AM, the MDS Coordinator explained she had recently figured out how to use the review history in [electronic health record system brand name redacted]. The MDS…

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

Based on observation, staff interviews, and clinical record review the facility failed to ensure ongoing coordination of care between facility staff and hospice staff for one of one resident reviewed for hospice (Resident #19). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 8/6/24, revealed Resident #19 scored 13 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. Per the assessment the resident received hospice care while a resident. On 9/25/24, review of Resident #19's Physician Orders present in the electronic health record (EHR) lacked an order for when the resident admitted to hospice services. Review a Transfer to Hospital Summary Note, dated 6/9/24 at 11:00 PM, revealed Resident was found by this nurse calling out help. Resident was checked on previously five minutes prior, was stable, comfortable, expressed no needs. Resident was found on floor on right side with bump to head and bleeding from top right forehead. Oxygen saturation at 87% on 3L (3 Liters), medic came 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.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to prevent reoccurrence of deficiencies. The facility reported a census of 51 residents. Findings include: The CMS 2567, dated 1/03/24 listed, in part, the following deficiencies cited during Recertification Survey and Complaint Survey: F550, F641, F657, F812, and F880. The current Recertificaton survey, conducted 9/23/24-9/26/24, also identified the above citations. During an interview on 9/26/24 at 10:18 AM, the Administrator reported the staff had been educated on all of the above tags and could not explain why the problems have re-occurred. The facility policy titled Quality Assurance Process Improvement Plan for the Facility, revised 8/29/24 instructed the following: a. The Facility monitors provider and facility adherence to quality standards through ongoing review of complaints,…

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, staff interview, and policy review the facility failed to wear appropriate Personal Protective Equipment (PPE) when providing care for residents with COVID-19, a tracheostomy and when performing wound care for 3 of 3 residents reviewed (Residents #257, #15 and #53). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) report for Resident #257 indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderate cognitive impairment. The MDS listed diagnoses included: pulmonary fibrosis, and pneumoconiosis due to asbestos and other mineral fibers (lung disease). The Care Plan, updated 9/20/24, indicated the resident had been diagnosed with COVID-19. The Care Plan instructed staff to follow contact and airborne isolation precautions. It further instructed staff to keep the door closed at all times unless safety was a concern. A review of the a Progress Note dated 9/19/20 at 12:19 PM revealed the resident tested positive for…

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

Based on observation, record review, and resident and staff interviews, the facility failed to provide appropriate urinary catheter care, and failed to follow standard infection control practices during 2 of 2 observations of urinary catheter care, for 2 of 2 resident's reviewed for catheter care (Resident #5 and Resident #7). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 4/30/24 revealed Resident #5 had diagnoses that included anxiety and generalized weakness, scored 15 out of 15 points on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive impairment or symptoms of delirium present, and required extensive support of staff for transfers to and from chair and bed, dressing, toileting, a urinary catheter used and the resident was unable to ambulate. A Physician Order date 5/19/23 directed staff to change the resident's urinary catheter monthly and as needed (PRN). An Indwelling Catheter problem initiated 6/1/23 on the resident's Nursing Care Plan directed staff: 1.…

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

Based on record review, and staff and resident interviews, the facility failed to ensure that residents received medications as ordered and directed by the physician, and resulted in a resident's transfer to a hospital Emergency Department for treatment of symptoms associated to medication withdrawal for 1 of 9 resident's reviewed (Resident #5). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 4/30/24 revealed Resident #5 had diagnoses that included anxiety and bipolar disorder, scored 15 out of 15 points on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive impairment or symptoms of delirium present, and required extensive support of staff for transfers to and from chair and bed, dressing, toileting, and unable to ambulate. Physician Orders directed staff to administer medications that included: 1. Chlorpromazine (an antipsychotic medication) 220 milligrams (mg) administered oral daily, ordered 3/17/24. 2. Ingrezza 40 mg administered oral daily, ordered 5/14/23. Ingrezza is…

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 and facility policy review, the facility failed to provide residents with an environment that maintains or enhances each resident's dignity by using the term and labeling residents as feeders. The facility failed to ensure residents were treated in a dignified manner for four residents within hearing distance in the dining area. The facility reported a census of 50 residents. Findings Include: 1. On 12/19/23 at 11:30 AM, during an observation of the dining area one of the two Dietary Aides plating the food, Staff Q, Server was heard referring to the resident's who need more assistance as the Feeder's. On 12/20/23 at 11:36 AM, during a dining observation a staff member stated, We need to make sure we get the Feeders. On 12/20/23 at 1:10 PM Staff P, Certified Nursing Assistant (CNA) was queried about food intake and advised, if the resident is a feeder we chart their food intake in Point Click Care, (PCC). Other residents are watched to make sure…

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, and facility policy review, the facility failed to provide residents assistance with dining and/or incontinence care for four of seventeen sampled residents (Residents #9, #25, #40, and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #45 dated 11/16/23 revealed the resident was rarely to never understood. Per this assessment, Resident #45 was dependent for eating. The Care Plan dated 9/19/23 documented, The resident has an Activities of Daily Living (ADL) self-care performance deficit related to (R/T) Dementia. The Intervention dated 9/19/23 revised 10/18/23 documented, Resident #45 needs assist x 1 with dining. On 12/19/23 at 8:27 AM, Resident #45 observed in the dining room. The resident had his spoon positioned upside down with the curved part of spoon faced down, and attempted to get food out of a dish. On 12/19/23 at 8:30 AM, the resident had a spoon in one hand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, the facility failed to ensure fall interventions consistently implemented, determine root cause analysis for falls, ensure residents at risks for falls provided appropriate supervision by staff, and ensure appropriate transport in a shower chair and wheelchair for four of twelve residents reviewed for accidents (Residents #4, #32, #34, and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #45 dated 11/16/23, revealed the resident was rarely to never understood. Per this assessment, the resident had fallen since admit, entry, or reentry, and had two or more falls with no injury. The Care Plan for Resident #45 dated 9/19/23, revised 11/30/23, documented, the resident is high risk for falls related (R/T) deconditioning, gait/balance problems, incontinence, psychoactive drug use. The Intervention dated 9/19/23 documented, ensure the resident is wearing appropriate footwear…

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, Pharmacy record review, staff interviews, and facility policy review, the facility failed to document a rationale or response to the Consultant Pharmacist's attempts for a Gradual Dose Reduction (GDR) for four of five residents reviewed (Residents #6, #31, #40 and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], identified Resident #6 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and had the following diagnoses: Arthritis, Non-Alzheimer's Dementia and Encephalopathy. The MDS also identified Resident #6 required substantial/maximal assistance with oral hygiene, showers, upper and lower body dressing, personal hygiene and repositioning in bed and also totally dependent on staff for toileting, putting on and removing footwear and transfers. A review of the Consultant Pharmacist's notes to the Physician revealed the following without a response from 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 and staff interviews the facility failed to distribute and serve food under sanitary conditions, when facility staff failed to wear hair restraints (hairnet, hat) that covered all exposed hair including long hair to prevent hair from contacting food, per current Food Code requirements. The facility reported a census of 50 residents. Findings Include: On 12/19/23 at approximately 11:45 AM, Staff R, Server- came into the kitchen to take a food cart to the dining area. Staff R had on a hair net which covered the top and sides of the head but did not cover the long dreadlocks. On 12/20/23 at 11:36 AM, Staff A, Server was observed behind the serving counter with long hair not contained in a hair net. On 12/18/23 11:15 AM, when queried, the Director of Culinary Services advised all staff are required to wear hair nets when in the kitchen or serving food. Observation on 12/19/23 at 8:11 AM, revealed Staff A, Server sneezed while behind the kitchenette/meal service area in the dining room, had gloves on, hand hygiene not observed, and the staff member proceeded 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.

Based on personnel record review, staff interview, and facility policy review, the facility failed to ensure one of three newly hired Nurses completed the Mandatory Reporter Abuse Training within the required timeframe of 6 months within hire (Staff M). The facility reported a census of 50 residents. Findings Include: 1. A review of the Human Resources (HR) file for Staff M, Registered Nurse (RN) revealed the following: a. A hire date of 10/12/22. b. Certificate of completion of Dependent Adult Abuse Mandatory Reporter Training dated 5/14/23 In an interview on 12/28/23 at 10:59 AM, the Director of Nursing (DON) reported Staff M is due to complete the Abuse Training. The DON also reported the HR manager will usually send out e-mails to department heads to inform them of which new employees need to complete the abuse training. The DON had just received an e-mail to inform her of the need a few days ago. A review of the facility policy titled: Abuse Prevention dated as last revised March 31, 2022 documented the following: Upon initial employment, each employee shall be required 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 clinical record review, observations, staff interviews, and facility policy review, the facility failed to ensure accurate coding on the Minimum Data Set (MDS) Assessment for catheter use, activities of daily living, and receipt of insulin injections for two of two residents reviewed for MDS accuracy (Residents #36 and #45). The facility reported a census of 50 residents. Findings Include: 1. The MDS Assessment for Resident #45 dated 11/16/23 revealed the resident rarely to never understood. Per this Assessment, the resident had an indwelling and external catheter. The Resident #45's Care Plan in the resident's Electronic Health Record (EHR) did not address presence of a catheter for the resident. The Physician Order dated 10/17/23, documented - Urinary Catheter: 16 French (F) 10 milliliter (ml) bulb one time a day starting on the 20th and ending on the 20th every month for cath care and as needed for occlusion or leakage as needed. On 12/20/23 at approximately 7:50 AM, Resident #45 observed in a Broda…

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 the facility policy the facility failed to Care Plan specialized services for the Preadmission Screening and Resident Review (PASRR) Level II and ensure residents received psychiatric services as recommended by the psychiatric provider for 1 of 1 residents reviewed for PASRR (Resident #25). The facility reported a census of 50 residents. Findings Include: The MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #25 scored an 11 out 15 on the Brief Interview for Mental Status (BIMS) exam indicating moderately impaired cognition. The MDS identified diagnoses for anxiety disorder and bipolar disorder. The MDS documented resident received antipsychotic and antidepressant. The PASRR Level II dated [DATE] and expired on [DATE] (short term approval) revealed the following: a. Specialized services for service and support: 1. Ongoing psychiatric medication management by a Psychiatrist, (to evaluate response and effectiveness of psychotropic medications 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 observation, clinical record review, staff interviews, and facility policy review, the facility failed to update Care Plans of two of ten residents reviewed (Residents #20 and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #20 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 and had the following diagnoses: Coronary Artery Disease, Heart Failure and Renal Insufficiency (kidney failure). The MDS documented Resident #20 required staff supervision or touching assistance with lower body dressing only and independent with the other activities of daily living. An observation of Resident #20 on 12/20/23 at 1:18 PM, revealed she sat in her wheelchair in her room which also had her bed with one ½ side rail up on the right side of the bed. A review of the Care Plan dated as last revised 8/9/23, revealed the Care Plan failed to have documentation the resident had side rails…

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 MDS assessment dated [DATE], revealed Resident #36 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated cognition intact. The MDS identified a diagnosis of diabetes mellitus (DM), and the resident received an injection 7 out of 7 days. The MDS documented the resident received an insulin injection 1 out of the last 7 days since admission/entry or reentry if less than 7 days. The Care Plan documented a focus area dated 11/2/23 for diabetes mellitus. The interventions dated 11/2/23 documented diabetes medication as ordered by doctor and monitored and documented for side effects and effectiveness; and resident took Lispro to assist with managing blood glucose levels. The Electronic Medical Record (EMR) identified a diagnosis of Type II DM without complications. The Physician Orders dated 10/13/23 revealed the following medication: a. Insulin Lispro Protamine and insulin Lispro subcutaneous suspension (75-25) 100 units/ml (milliliter)- Inject 10 Units subcutaneously in 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 2. The MDS assessment dated [DATE], revealed Resident #25 scored a 11 out 15 on the Brief Interview of Mental Status (BIMS) exam which indicated cognition moderately impaired. The MDS identified the resident dependent with toileting and needed substantial/maximal assistance with upper and lower body dressing and rolling from right to left. The MDS documented an indwelling catheter for the resident. The Care Plan revealed a Focus Area dated 6/10/23 for an indwelling catheter. The interventions dated 6/1/23 to monitor and document intake and output as per facility policy. During an observation on 12/19/23 at 2:00 PM, Resident #25 sat in her recliner with the catheter bag hooked to the trash can with dark yellow urine and the bottom of the catheter bag touched the floor. During an observation on 12/20/23 at 12:38 PM, Resident #25 catheter bag laid on the floor next to the recliner while resident sat in the recliner with her feet elevated in her room. During an interview on 12/21/23 at 11:30 AM, Staff F, Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to document an assessment and education provided for one of two residents reviewed with side rails. (Resident #20). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set, dated [DATE] identified Resident #20 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 and had the following diagnoses: Coronary Artery Disease, Heart Failure and Renal Insufficiency (kidney failure). It also identified Resident #20 required staff supervision or touching assistance with lower body dressing only and independent with the other activities of daily living. An observation of Resident #20 on 12/20/23 at 1:18 PM, revealed Resident #20 sat in her wheelchair in her room which also had her bed with one ½ side rail up on the right side of the bed. A review of the Care Plan dated as last revised 8/9/23 revealed the Care Plan did not have documentation…

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

Based on record review, state on-line licensure verification and staff interviews, the facility failed to obtain a current nursing license for one of three nurses reviewed for new hires (Staff L). The facility reported a census of 50 residents. Findings Include: A review of the Human Resources (HR) file for Staff L, Registered Nurse (RN) revealed the following: a. Hire date of 10/17/23. b. New Employee Orientation Checklist (reviewed 12/21/23) did not have documentation to show a copy of the RN license had been obtained. c. Iowa Board of Nursing verification of RN licensure dated as completed 12/27/23. In an interview on 12/28/23 at 10:38 AM , Staff I, Certified Nursing Assistant (CNA) reported she has seen Staff L toilet residents and answer call lights. In an interview on 12/28/23 at 10:59 AM, Staff L, RN reported upon hire, no one made a copy of her nursing license. She had a temporary license as she was a nurse in another state. She had driven to Des Moines where they issued her a temporary license. When asked how often she helps with resident cares on the floor, she reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and family interviews, and facility policy review, the facility failed to offer or obtain routine dental services for 3 of 3 residents (Residents #8, #37, and #40) reviewed for dental services. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #8 required set up assistance for oral hygiene and had obvious or likely cavity or broken natural teeth. Resident #8 coded as rarely or never understood, had both short term and long term memory problems, and indicated moderate impairment in ability to make decisions regarding tasks of daily life. Diagnoses included: Leukemia (in relapse), atrial fibrillation, arthritis, asthma, and depression. The Care Plan, initiated 7/10/23, revealed a Focus Area for self-care performance deficit in Activities of Daily Living (ADL) related to musculoskeletal impairment and indicated Resident #8 required assistance with oral care and had a partial dental plate. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to follow the proper transmission based precautions for one of one residents reviewed with contact precautions (Resident #14) and failed to follow the recommendations required for Legionella. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and had the following diagnoses: Pneumonia, Urinary Tract Infection and Respiratory Failure. The MDS also identified Resident #14 required set up or clean up assistance with most activities of daily living and required tracheostomy care with suctioning. The Nurse Practitioner Note dated 12/15/23 documented the following: Post inpatient hospitalization for acute Encephalopathy secondary to Urinary Tract Infection (UTI) and Clostridium Difficile (C-Diff) colitis. She was discharged…

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.