Accura Healthcare of South Des Moines

Based on direct observation, family and staff interviews, the facility failed to appropriately supervise and have interventions in place to ensure the resident's individual safety in the Chronic confusion and dementing illnesses (CCDI) unit. The facility reported a census of 28 in the CCDI unit and a total census of 71. Findings include: In a confidential interview on 08/19/24 at 10:42 AM with a resident Family Member A, they stated they felt they had to take over many of the cares their family member received because the facility staff had a pattern of ignoring their loved ones needs. They stated they were performing several of their family members activities of daily living after discovering their family member soiled with dried feces on them. In a confidential interview on 08/19/24 02:22 PM with Resident Family Member B, they stated their loved one had been found on multiple occasions heavily soiled with dried feces on their body. They stated staff members often told them the resident had refused all cares, and had not showered in weeks as a result. A continuous direct…

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, observation, staff interviews, and policy review the facility failed to utilize infection control techniques in order to prevent cross contamination for 2 of 3 residents reviewed for catheter care, treatments, and dressing changes (Resident #6 and #28). The facility also failed to ensure staff changed gloves and performed hand hygiene when contaminated for two of three residents observed. The staff failed to utilize a barrier and disinfect contaminated equipment and surfaces after use for 1 of 3 units observed. The facility staff also failed to don personal protective equipment on a resident on enhanced barrier precautions prior to catheter care for 1 of 3 units observed. The facility also failed to provide peri-care in a manner to prevent cross-contamination and infection for 1 of 3 residents observed for peri-care. The facility also failed to disinfect resident care devices when soiled for 2 of 3 residents observed during incontinence/catheter cares (Resident #6 and #41). The…

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

Based on clinical record review and staff interview the facility failed to provide the resident/resident representative notice of the bed hold policy at the time of transfer for hospitalization for two (Residents # 36 and #43) of three residents reviewed. The facility reported a census of 71 residents. Findings include: 1.A Minimum Data Set for Resident #36 dated 6/6/24, included diagnoses of heart failure and diabetes. A Brief Interview for Mental Status score of 15 indicated no cognitive impairment for decision-making. Review of resident's progress notes documented the resident was admitted to the hospital 5/26/24 and returned to the facility 6/3/24. Review of resident's clinical record lacked documentation of notification to the resident/ resident's representative regarding the bed-hold policy when transferred to the hospital. 2. Minimum Data Set for Resident #43 dated 8/8/24, included diagnoses of diabetes and cancer. A Brief Interview for Mental Status score of 15 indicated no cognitive impairment for decision-making. Review of resident's progress notes documented the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to develop and implement a Baseline Care Plan that included anticoagulant (blood thinner), antipsychotic, and antidepressant medications and monitoring for one (Resident #76) of three residents reviewed. The facility reported a census of 71 residents. Findings include: A Minimum data set (MDS) assessment dated [DATE] for Resident #76, included diagnoses of heart failure, anxiety disorder, and mood disorder. Review of resident's order summary report dated 8/21/24, listed the following medications: 1. Apixaban (anticoagulant) 5 milligrams (mg)- 2 times daily. 2. Duloxetine(antidepressant) 40 mg. in the morning and 60 mg. at bedtime. 3. Risperdal (antipsychotic) 1 mg.- 2 times a day. Review of resident's Baseline Care Plan, dated 8/8/24, lacked documentation of the anticoagulant, antidepressant, and antipsychotic medications. Interview on 8/22/24 at 10:27 AM, the Director of Nursing stated expectation for the medications to be included 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.

Based on clinical record review, resident, family, and staff interviews, the facility failed to appropriately provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being. Clinical record review revealed the nursing staff failed to provide thorough assessment, did not contact the resident's physician in a timely manner or provide treatment for 1 of 18 residents reviewed. (Resident#61). Findings include: The Minimum Data Sample (MDS) for Resident #61, dated 06/27/24, documented a brief interview for mental status score (BIMS) of 99, indicating the resident was unable to complete the interview. The MDS documented relevant diagnoses of Non-Alzheimer's Dementia, anxiety disorder, and bipolar disorder. The Care Plan, last updated on 07/15/2024, documented Resident #61 is dependent on staff to meet her emotional, intellectual, physical, and social needs. Review of a health status note dated 07/22/2024 documented a phone call between a resident family member and Staff M, Registered Nurse (RN), in which the family…

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, competency checklist, and a mechanical lift manufacturer user instruction manual, the facility staff failed to utilize safe transfer technique when they used a mechanical lift (Hoyer) transfer device for 1 of 3 residents observed for transfers and required a mechanical lift for transfers (Resident #23). The facility also failed to ensure adequate ventilation and temperature controls in a room that contained servers and electronic devices. The facility also failed to ensure bathroom call lights accessible for residents and staff for 1 of 3 units observed. The facility reported a census 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had diagnoses of dementia, muscle weakness, and anxiety. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severely impaired cognition. The MDS documented the resident had dependence on staff 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 clinical record review, observation, staff interview, and the facility policy review, the facility staff failed to provide complete incontinence care for one of three residents reviewed (Resident #23). The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had diagnoses of dementia. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The MDS documented the resident had incontinence, and had dependence on staff for toileting hygiene. The Care Plan revised 2/8/24 revealed the resident had a self-care deficit in activities of daily living and had incontinence. The resident required maximum assistance for bed mobility and dressing. The care plan directed staff to clean the peri-area after each incontinence episode. During observation on 08/20/24 at 07:44 AM, Resident #23 [NAME] in bed while Staff C, certified nursing assistant (CNA),…

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 policy review the facility failed to assure a medication error rate of less than 5%. During observation of medication administration, the facility had 5 errors out of 37 opportunities for error resulting in an error rate of 13.51% (Residents #69). The facility identified a census of 71 residents Findings include: During observation on 08/20/24 at 3:28 PM, Staff A, Licensed Practical Nurse (LPN), checked the electronic health record (EHR) and obtained a Styrofoam cup with hot water. Staff A reported the hot water would help dissolve the pills better. Staff A prepared the following medication for Resident #69: 1. Amantadine (anti-seizure/tremor medication) 15 milliliters (ml) 2. Docusate sodium (stool softener) 30 ml 3. Atorvastatin (for cholesterol)10 milligrams (mg) 4. Eliquis (blood thinner) 5 mg 5. Metoprolol (for blood pressure) 25 mg Staff A crushed the pills (atorvastatin, eliquis, and metoprolol) and placed them into the liquid medication and warm water mixture in the Styrofoam cup. Staff A then stirred 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 clinical record review, observation, staff interview, and policy review, the facility failed to follow the physician's orders and administer medications as ordered. Facility staff administered medications through a gastrostomy tube instead of by mouth as ordered for 1 of 7 residents observed during medication administration. The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had diagnoses of stroke, non-Alzheimer's dementia, seizure disorder, and dysphagia. The MDS documented the resident had impaired short-term and long-term memory and severely impaired decision making skills. The MDS indicated the resident on a mechanically altered diet and had a tube feeding. The Care Plan revised 5/3/24 revealed the resident had a Peg tube placed during hospitalization. The care plan directed staff to administer medications as ordered. The Medication Administration Record (MAR) dated 8/1/24 to 8/31/24, revealed Staff A, Licensed…

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, and staff interviews, the facility failed to hold a medication as directed per the physicians orders for which caused a resident to reschedule an appointment for 1 or 3 residents reviewed. (Resident #1). The facility reported a census of 78 residents. Finding include: 1. The Annual Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 2/21/24, documented diagnosis for which included hypertension, anxiety, depression and psychotic disorder. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13, for which indicated no impairments with decision making or memory problems. The MDS documented the resident had adequate hearing and is able to make self understood and had the ability to understand others. The MDS documented the resident required partial to moderate assistance with personal hygiene. An After Visit Summary Dated 2/15/24, documented next appointment on 4/4/24 at 9:30 a.m., and you will need to stop the following medications 48 hours prior to your appointment, Tramadol (pain…

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 and resident interview, the facility failed to provide two baths a week as directed for 2 out of 4 residents reviewed (#1 and #4). The facility reported a census of 78 residents. Findings include: 1. The Annual Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 2/21/24, documented diagnosis for which included hypertension, anxiety, depression and psychotic disorder. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13, for which indicated no impairments with decision making or memory problems, had adequate hearing, and was able to make self understood, and had the ability to understand others. The MDS documented that the resident required partial to moderate assistance with personal hygiene and showers/bathing activity. Review of electronic documentation of task completion for Resident #1 revealed the facility failed to provide baths between April 8, 2024 and April 15th, 2024. In an interview on 4/23/23 at 9:50…

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 have 1 of 3 residents seen at least once every 60 days by the physician. (Resident #1) The facility census was 78 residents. Finding include: 1. The Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 2/21/24, documented diagnosis for which included hypertension, anxiety, depression and psychotic disorder. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13, for which indicated no impairments with decision making or memory problems, and had adequate hearing, and was able to make self understood The MDS documented the resident had the ability to understand others, and required partial to moderate assistance with personal hygiene. The Clinical Record for Resident #1 documented that the Physician visited the patient on these dates: *10/26/23 (Behavioral Health visit) *3/11/24 (Physician Assistant visit) The clinical record lacked documentation of the primary care physician seeing the resident between 10/26/23 and 3/11/24. Interview on 4/25/24 at 1:22…

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 resident and staff interviews, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 1 of 3 residents reviewed . (Resident #1). The facility identified a census of 78 residents. Findings include: 1. The Annual Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 2/21/24, documented diagnosis for which included hypertension, anxiety, depression and psychotic disorder. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13, for which indicated no impairments with decision making or memory problems. The MDS documented the resident had adequate hearing and was able to make self understood, and had the ability to understand others The MDS indicated the resident required partial to moderate assistance with personal hygiene and showers/bathing activity On 4/23/24 at 9:45 a.m., Resident #1 stated that it could take the staff over a half hour to answer the call light. During an interview on 4/22/24 at 3:15 p.m., Staff A, Certified Nursing Assistant (CNA) confirmed 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 resident interviews, staff interviews, and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time, under 15 minutes. Residents and staff reported having low staffing caused missed or delayed cares. The facility reported a census of 72 residents. Findings include: 1. Record review of Resident #2 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #2 required dependence on one staff member for performing activities of daily living. During an interview on 2/26/24 at 10:40 AM Resident #2 stated he had to wait on average over 30 minutes for staff to answer his call light and between hours of 11 PM - 7 AM it's a lot longer, up to a few hours. 2. Record review of Resident #12 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #12 required dependence…

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, clinical record review, and staff interview, the facility failed to treat residents with dignity and respect throughout cares provided for 3 of 9 residents reviewed (Resident #2, Resident #12, and Resident #14). The facility reported a census of 72 residents. Findings include: 1. Record review of Resident #2 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #2 required dependence on one staff member for performing activities of daily living. During an interview on 2/26/24 at 10:40 AM Resident #2 stated his legs sometimes were in a lot of pain and he couldn't lift them up on his own when getting into his bed. He wasn't able to get into bed completely and would push a call light but on many occasions no one came to assist him so he would lay down in bed with his legs still on the floor. He said it made him feel less than a man. 2. Record review of Resident #12 Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, documentation review, and facility policy review, the facility failed to report an allegation of abuse within two (2) hours to the State Survey Agency related to mistreatment of 1 resident (Resident #12). The facility reported a census of 72 residents. Findings include: Record Review of Resident #12 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS listed diagnoses of seizure disorder or epilepsy, anxiety disorder, depression, and post traumatic stress disorder (PTSD). The MDS documented Resident #12 required dependence on 1-2 staff members for performing most activities of daily living (ADLs). During an interview on 2/26/24 at 10:40 AM Resident #12 stated recently he felt a CNA was rough with him while providing hands-on assistance and it made his PTSD flare up, he felt scared and reported it to the Director of Nursing (DON). A review of the facility report submitted to the State…

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 the clinical record reviews, resident and staff interviews, the facility failed to provide residents with the assistance of Activities of Daily Living (ADLs) for 4 out of 6 residents reviewed for baths/showers (Residents #31, #49, #56, and #61). The facility reported a census of 78 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #31 entered the facility on 6/20/23. The MDS also documented a Brief Interview for Mental Status (BIMS) of 06, indicating severe cognitive impairment. The MDS documented Resident #31 did not have functional abilities for transfers in/out of tub/shower and required a total assistance of two or more staff members. During an observation on 1/22/24 at 11:00 AM, Resident #31 appeared to have dull and greasy hair. Upon review of Resident #31's Electronic Health Record (EHR), the last documented bath/shower occurred on 12/28/23. The Progress Note in the EHR on 1/8/24 documented a shower attempted three times but was refused by the resident.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, the facility failed to provide sufficient number of staff to provide Activities of Daily Living (ADL) assistance for 4 out of 5 residents reviewed (Resident #31, #49, #56 and #61). The facility reported a census of 78 residents. Findings include: 1. During an observation on 1/22/24 at 11:00 AM, Resident #31 appeared to have dull and greasy hair. During a review of Resident #31's Electronic Health Record (EHR), the last documented bath occurred on 12/28/23. 2. During an observation on 1/23/24 at 3:00 PM, Resident #61 appeared to have dull and greasy hair. The Minimum Data Set (MDS) dated [DATE] documented Resident #61 entered the facility on 12/1/23. The MDS also documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. In an interview with Resident #61 on 1/24/24 at 10:00 AM, she stated she hadn't been receiving showers per her preference due to low staffing. She revealed if the facility had enough staff then she would get…

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

Based on record review, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities in order to address problem-prone areas and create a plan for improvement. The facility reported a census of 78 residents. Findings include: The Centers for Medicare and Medicaid Services 2567, dated 11/2/23, listed the following concerns: F550, F568, F607, F656, F657, F677, F684, F725. The untitled audit sheets related to the 11/2/23 survey revealed the following: F550 lacked documentation of an audit completed between 11/30/23 and 1/25/24. F568 was blank and lacked documentation of audits completed. F607 was blank with the exception of 2 yes entries but lacked documentation of an audit completed. F656 lacked documentation of an audit completed after 12/1/23. F657 lacked documentation of an audit completed after 12/1/23. F677 was blank and lacked documentation of audits completed. F684 lacked documentation of an audit completed after 12/4/23. F725 was blank and lacked documentation of audits completed. An Education Sheet documented a 12/21/23 QA meeting.…

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, resident interview, and staff interview, the facility failed to provide quarterly financial statements for 3 of 3 residents reviewed for personal funds. (Residents #15, #35, and #36). The facility reported a census of 78 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/15/23, listed Resident #15's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 1/23/24 at 9:35 a.m., Resident #15 stated he did not receive monthly financial statements from the facility but he wished he did. 2. The MDS assessment tool, dated 12/13/23, listed Resident #35's BIMS score as 15 out of 15, indicating intact cognition. On 1/22/24 at approximately 10:00 a.m., Resident #35 stated she did not receive monthly financial statements from the facility. 3. The MDS assessment tool, dated 1/19/24, listed Resident #36's BIMS score as 14 out of 15, indicating intact cognition. On 1/22/24 at approximately 10:10 a.m., Resident #36 stated she did not receive monthly financial statements from the facility. 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.

Based on employee file review, policy review, and staff interview, the facility failed to complete a criminal background check to include a record check evaluation for 1 of 3 staff members reviewed (Staff A). The facility reported a census of 78 residents. Findings include: The facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated 10/19/22, stated the facility would conduct criminal record checks for potential employees. A Record Check Evaluation, ran by a former facility and dated 3/28/23, stated Staff A may work. A Single Contact License and Background Check, dated 12/5/23, stated further research was required for the staff member's criminal history background check and directed to await the final response for criminal history. An untitled, undated facility document listed the hire date for Staff A Registered Nurse (RN) as 12/6/23. An Iowa Criminal History Misdemeanor Convictions Only document, dated 12/10/23, listed an 11/1/23 arrest for Staff A for theft in the third degree. The facility lacked documentation of 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 electronic record reviews, staff interview, and resident interview, the facility failed to develop a comprehensive, person-centered Care Plan for 2 out of 3 residents reviewed (Resident #19 and #61). The facility reported a census of 78 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #61 entered the facility on 12/1/23. The MDS also documented a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition. The MDS documented the functional abilities and goals for showers, toilet transfers, sit to stand, and chair/bed-to-chair transfers as requiring partial/moderate assistance of at least one staff member with lifting, holding or supporting with less than half the effort. The Care Plan initiated on 12/07/23 did not document Resident #61's current functional status, a minimum of one staff member needed to assist with showers, toilet use, or transfers. During an interview with the Resident on 1/23/24 at 3:30 p.m., she expressed she relied on staff to…

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

Based on clinical record review, resident interview, and staff interview, the facility failed to conduct quarterly care conferences which included the resident and/or the resident's representative and the interdisciplinary team for 3 of 3 residents reviewed (Residents #66, #67, and #68). The facility reported a census of 78 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool for Resident #66, dated 12/18/23, listed a Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. A 12/27/23 Care Conference Review contained multiple blank entries such as the date of the care conference review, attendees, nursing services information, and social services documentation. The form lacked documentation of an attempt to invite the resident's representative. 2. The MDS assessment tool for Resident #67, dated 12/29/23, listed a BIMS score as 4 out of 15, indicating severely impaired cognition. A 1/3/24 Care Conference Review contained multiple blank entries such as the date of the care conference review, attendees, nursing…

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, resident interview, and staff interview, the facility failed to carry out a physician ordered intervention by failing to ensure the application of compression socks (used to prevent blood clots and aid in circulation) for 1 of 3 residents reviewed for assessment and intervention (Resident #56). The facility reported a census of 78 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 11/28/23, listed diagnoses for Resident #56 which included diabetes, coronary artery disease (a buildup in the arteries), and edema (swelling). The MDS stated the resident required supervision and touching assistance for lower body dressing and putting on and taking off footwear. The MDS listed the resident's Brief Interview for Mental Status (BIMS) as 15 out of 15, indicating intact cognition. An 11/5/21 Care Plan entry stated the resident had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and the need for assistance with personal cares. A 9/22/23 Order Details report listed an order 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, resident, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. The facility identified 31 other residents reside on the CCDI unit. Additionally, the facility failed to provide a safe mechanical lift transfer for 1 of 3 residents reviewed (Resident #1). The facility further failed to provide a safe environment on the CCDI unit allowing residents to exit the unit to a secured outdoor area without staff knowledge or consent due to the door alarm being deactivated. Findings include: 1. The MDS for Resident #2 dated 9/20/2023 documented severe cognitive impairment. The MDS documented no hallucinations or delusions and no physical or verbal behavioral symptoms directed towards others. The MDS also documented they wandered 1-3 days of the week during the observation period. The MDS documented the resident independent for bed mobility, transfer, toilet use, and…

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

Based on observation, record review, resident, staff interviews, and facility policy review the facility failed to have sufficient staff to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. Staff left the residents unattended and went to the nurse's station located in the middle of the unit to get help because there was no call light available in the room to summon help, no nurse was on the unit, and the CMA and the other CNA were in the enclosed nurses station and couldn't hear her calling for help. The facility identified 31 other residents reside on the CCDI unit. Additionally, the facility failed to have sufficient staff to provide a safe mechanical lift transfer for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 10/13/23 documented a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. The MDS further documented the resident dependent 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 observations, staff and resident interviews, staff posting sheets, nursing staff schedules, and the Facility Assessment, the facility failed to have a sufficient number of nursing staff on duty on a 24 hour basis to adequately and safely meet the residents' needs. Findings include: 1. On 10/23/23 at 12:10 PM, the Administrator stated the facility has no current Director of Nursing. On 10/24/23, lunch service was observed. The facility document titled Meal Times states lunch service is from 11:00-12:00 in the main dining room and meal service for the Station 2 cart begins at 11:15 am. The following observations were made on 10/24/23: 12:10 PM the second meal cart for Station 2 was ready to go to the floor but the first meal cart had not yet been returned to the kitchen. At 12:18 PM Staff I, CMA came to the dining room and stated that there is not enough staff to serve and meal service had just begun a few minutes earlier. 12:22 PM: The second meal cart was taken to Station 2 by Staff L, cook, but 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 employee interviews and facility documentation, the facility failed to have full time Registered Nurse Director of Nursing. The facility reported a census of 81 residents. Findings include: The employee roster provided by the facility listed the Nursing Management team to include the Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN); the Quality Assurance/Infection Control nurse, LPN and the MDS Coordinator, Registered Nurse (RN). On 10/23/23 at 12:10 PM, the Administrator stated the facility has no current Director of Nursing (DON). She stated the facility has three nurse managers who have been designated to split the tasks of the DON. On 10/25/23 at 12:36 PM, the MDS Coordinator, RN stated she was a DON at a former facility and she helps out as much as possible with DON duties at this facility. She stated she felt burned out from several years of being a DON and does not want the position of DON at this facility. She reiterated she has been willing to share her knowledge but she is not an interim DON and her title is MDS Coordinator. On 10/26/23 at…

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 resident interviews, staff interviews, resident council notes, and facility policy review, the facility failed to address issues brought forward from the Resident Council. The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) of Resident #49 dated 9/23/23 identified a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS of Resident #53 dated dated 10/13/23 identified a BIMS score of 15 which indicated cognition intact. The MDS of Resident #56 dated 8/28/23 identified a BIMS score of 14 which indicated cognition intact. The MDS of Resident #57 dated 10/4/23 identified a BIMS score of 15 which indicated cognition intact. On 10/25/23 at 10:03 AM, the State Surveyor met as a group with Residents #49, #53, #56 and #57, all active members of the Resident Council. Resident #56 was identified as President of the Resident Council. Resident #56 stated the night shift Certified Nurse Aides (CNAs) do not answer call lights. He stated he has witnessed the CNAs sitting with their backs turned so they cannot…

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 resident interview, staff interviews, and resident [NAME] of Rights, the facility failed to facilitate the residents receiving unopened mail delivered to the facility. The facility reported a census of 81 residents. Findings include: On 10/25/23 at 10:28 am, Resident #56 stated at times the mail is already opened when it is delivered to the residents. On 10/25/23 at 10:29 am, the Activities Director stated at times when she is given the mail to distribute to residents, it is already opened. She stated the mail first goes to the Business Office Manger and it is then given to her to pass on to the residents. She stated she had delivered mail earlier in the day on 10/25/23 and some of it was already opened. On 10/25/23 at 11:03 am, the Business Office Manager (BOM) stated that all personal mail is delivered to all of the residents and all mail is delivered to the cognitively aware residents. She remarked if the resident is not cognitively aware, she just deals with it. She stated mail such as benefits statements from insurance companies, described as mail that states This 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 observation, resident and staff interview, and policy review, the facility failed to provide a safe and homelike environment by failing to exercise reasonable care for the protection of the resident's property from loss or theft for 4 of 4 residents reviewed for missing belongings (Resident #49, #15, #31, & #284) and failed to maintain a safe, clean, comfortable, and homelike environment during remodeling of the facility. The facility reported a census of 81 residents. Findings include: 1. On 10/23/23 Resident #49 stated she was missing two pair of pants (one black with brown and white stripes; one blue with lavender and white stripes) and a T-shirt since July 2023. She stated the housekeeping manager was not able to locate them. Resident #15 stated he was missing two black T-shirts with designs that had not been located. On 10/30/23 at 11:43 AM, Staff W, laundry personnel stated the process for personal item identification is residents are asked upon admission if the facility will be laundering 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 employee file review, communication from facility staff, and facility policy review, the facility failed to ensure 1 of 6 staff members (Staff E) completed the two hour Dependent Adult Abuse training within 6 months of hire date. The facility further failed to complete a Single Contact Repository (SING) background check prior to hire for 1 of 6 staff members (Staff C). The facility reported a census of 81 residents. Findings include: 1. Review of employee file of Staff E, housekeeper, revealed a hire date of 6/22/22. The file lacked documentation of an Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse (DAA) Mandatory Reporter training certificate. On 10/26/23 at 12:53 PM the Administrator provided a DAA training certificate for Staff E dated 10/26/23. 2. Review of employee file of Staff C, Certified Nurse Aide, revealed a hire date of 4/12/23. Staff C was a rehire from previous employment at the facility in 2021. Staff C's employee file lacked documentation of a SING background check for the current hire date. On 10/25/23 at 12:58 PM, via email, 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 clinical record review, staff interviews, and policy review, the facility failed to develop comprehensive Care Plans for 5 of 19 residents reviewed (Resident #19, #31, #49, #52 and #77). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses of bipolar disorder, psychotic disorder, anxiety disorder, and depression. The Care Plan revised on 7/28/21 revealed the resident had impaired thought processes as exhibited by diagnoses of bipolar disorder, depression, anxiety, and delusional disorder. The staff directives included to administer psychotropic medications as ordered and monitor for medications side effects. The order summary report revealed a STAT (immediate) order on 5/27/23 to send the resident to the hospital for psychiatric evaluation due to suicidal thoughts. The Progress Notes dated 5/27/23 at 6:07 PM, revealed the resident had thoughts of harming herself and ending her life, and wanted to die.…

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, and policy review, the facility failed to ensure residents received adequate frequency of baths/showers per the residents preference for 5 of 6 residents reviewed for baths/showers (Residents #15, #35, #49, #87, and #284). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 6/10/23 revealed Resident #87 had diagnoses of diabetes and urinary tract infections. The MDS documented the resident had required assistance of one staff for bathing. The MDS documented choosing the type of bath or shower was very important to her. The Care Plan revised on 5/8/23 revealed the resident had an ADL (activities of daily living) self-care deficit related to impaired mobility and functional abilities. The staff directives included assistance of one for bathing, and bathing encouraged twice a week and as necessary. The electronic health record included a weekly wound observation tool dated 8/30/23 but no…

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 interview, and policy review the facility failed to secure medications in a locked medication cart for two of four medication carts. The facility reported a census of 81 residents. Findings include: 1. On 10/24/23 at 4:00 PM, an unlocked medication cart sat in the middle of the 200 hall between rooms [ROOM NUMBERS], with no staff observed in the area. The medication cart drawers had multiple resident medications, including antipsychotic medications, heart medication, blood pressure medications, etc. The top drawer of the medication cart had multiple medication cups stacked inside of each other and each medication cup had pills in various colors, shapes, and sizes, with a number and letter A or B listed on them. The computer on top of the medication cart was open and had resident pictures, names, and room numbers listed on the screen, giving access to resident medical record information. On 10.24.23 at 4:10 PM Staff F, certified medication aide (CMA), reported he was assigned to 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, staff interviews, and the facility policy review, the facility failed to provide functional furniture appropriate to the residents needs for 11 out of 32 rooms reviewed. The facility reported a census of 81 residents. Findings include: During an observation on 10/23/23 at 11:40 AM of the CCDI (Chronic Confusion or Dementing Illness) unit, 11 out of 32 resident rooms were not furnished with functional furniture, to include bedside storage tables, chairs, and a place to store clothing in an organized manner, reachable by residents. Some rooms had socks and smaller clothing items stored in paper boxes under the sink and some closets had clothing stored directly on the floor. During an interview with the Administrator on 10/25/23 at 10:57 AM, she stated resident rooms in the CCDI unit were furnished with a bed and a TV upon admission and if the facility had any donated furniture then they would make it available upon request. She further stated that all other resident rooms in the facility were furnished with a bed and a bedside table with storage shelves. A review…

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, family and staff interviews, the facility failed to adequately equip residents with a communication system to call for assistance from a bedside and from toilet and bathing facility for 32 residents in the facility. The facility reported a census of 81 residents. Findings include: During an observation on 10/23/23 at 10:41 AM of the CCDI (Chronic Confusion or Dementing Illness) unit, 32 resident rooms, including private bathrooms and the main shower room, did not have a communication/call system available to call for assistance. During a family member interview on 10/25/23 at 12:45 PM, a concern was brought up in regards to no call light system available for their mother to use who was still independent with toilet use. During an interview with another family member on 10/25/23 at 04:54 PM, the family member was concerned about his mother not being able to call for help with her history of falls. He stated that she would use it if she was provided a call light. During an interview with the Administrator on 10/25/23 at 10:57 AM, she stated that floor staff made…

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 observations, record review, staff interview, and policy review, the facility failed to provide residents with facial cleaning after meals for 1 of 8 residents reviewed for dignity (Resident #1). The facility reported a census of 81 residents. Findings include: On 10/23/23 at 1:48 PM, Resident #1 was observed with a red substance around her mouth. She stated it was the sauce from lunch. The tray had already been picked up. She stated she asked staff to clean it and no one came back. The resident stated she didn't like sitting in her room with food sauce on her mouth. The residents quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was not able to complete the interview. It also listed diagnoses of heart failure, Alzheimer's disease, psychotic disorder, seizure disorder, anxiety, depression, and paraplegia. The MDS revealed the resident required one-person, limited assistance with personal hygiene,…

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, interviews, record review, and policy review, the facility failed to maintain Medicaid funded Resident Trust Fund (RTF) amounts exceeding $50 in an interest-bearing account. The facility also failed to secure RTF money held at the facility for 19 residents. The facility reported a census of 81 residents. Findings include: On 10/24/23, an Interview with Residents #15, #35, and #36 indicated the residents did not receive a statement of funds or a receipt of earned interest for their Medicaid funded RTF accounts. On 10/31/23 at 4:25 PM, the Business Office Manager (BOM) stated there were no resident RTF funds held in an interest-bearing account. There were no interest statements available. On 11/01/23 at 9:17 AM, the BOM stated there were 19 residents in the facility who had RTF accounts. On 11/01/23 at 8:55 AM, the BOM's office door was observed opened with no staff present within view. The cabinet where RTF funds were kept had keys hanging out of the locking mechanism. The mechanism was noted to be unlocked position (extended). Between 8:55 AM and 9:17 AM, five…

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 interviews, record review, and policy review, the facility failed to provide individual financial records through quarterly statements for 3 of 3 residents (Residents #15, #35, and #36). The facility identified a census of 81 residents. Findings include: On 10/24/23, an Interview with Residents #15, #35, and #36 indicated the residents did not receive a statement of funds for their Medicaid funded Resident Trust Fund (RTF) accounts. On 10/25/23 at 10:45 AM, the Business Office Manager (BOM) stated she mailed or hand delivered the RTF statements to the residents every quarter or upon request but residents did not sign for receipt. She stated the RTF statements were tracked on a spreadsheet but admitted it had not been updated in a couple of months. On 10/31/23 at 4:25 PM, the BOM stated there were no resident RTF funds held in an interest-bearing account. There were no interest statements available. On 11/01/23 at 9:17 AM, the BOM stated there were 19 residents in the facility who had RTF accounts. On 11/01/23 at 1:36 PM, the Administrator stated account statements were…

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 accurately complete a Minimum Data Set (MDS) assessment for 1 of 19 resident's reviewed in the sample (Residents #52). The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had a diagnosis of COVID-19. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicated cognition intact. The MDS revealed oxygen not marked under section O /special treatments. The Progress Notes revealed: a. On 9/26/23 at 2:16 PM resident on oxygen at 2 liters per nasal canula (NC), and started on an antibiotic for bronchitis. b. On 9/28/23 at 4:11 PM, the resident remained on oxygen due to oxygen saturation dropped to 88% on room air. c. On 9/29/23 at 5:44 AM the resident complained of shortness of breath. Oxygen increased from 1.5 to 2 liters for comfort. Observations revealed the following: a. On 10/23/23 at 12:30 PM, the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interviews, and policy review, the facility failed to involve the resident and resident's representative in care conferences, and in making decisions about his or her plan of care and care plan development for 1 of 4 residents reviewed for care conferences (Resident #31). Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 admitted to the facility on [DATE], and had diagnoses of non-traumatic brain dysfunction, cognitive communication deficit, and dementia. The MDS documented the resident had a Brief Interview of Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS indicated the resident deemed having family involved in a discussion about her care as very important. The baseline Care Plan dated 6/20/23 revealed the resident's daily preferences for family or significant other involvement in her care discussions. A care conference review document dated 10/17/23 had only notes listed from dietary,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interviews the facility failed to properly discharge a resident by failing to provide a 30-day discharge notice and necessary discharge paperwork for 1 of 1 resident reviewed (#49). The facility reported a census of 81 residents. Findings include: The Progress Notes and Electronic Health Record (EHR) uploaded files indicated Resident #49 was not offered a bed-hold prior to or within 24 hours after she transferred from the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating intact cognition. It also listed diagnoses of Cerebrovascular Accident (stroke) and depression. The Electronic Health Record's (EHR) clinical census report (payor source) indicated the resident was billed as Medicaid and was listed as hospital unpaid leave status while she was in the hospital between [DATE] and [DATE]. The census report also revealed the resident's billing stopped 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 clinical record review, speech therapy recommendations, and staff interviews, the facility failed to follow speech therapy recommendations for a resident who had dysphagia for 1 of 7 residents reviewed (Resident #44). The facility also failed to obtain daily weights and notify the physician as ordered when a resident had a weight gain greater than 3 pounds in a day or 5 pounds in a week for 1 of 7 residents reviewed, and also failed to complete follow up skin assessments for 1 of 7 residents reviewed for a skin condition (Resident #87). The facility reported a census of 81 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had diagnoses of cerebrovascular accident and aphasia. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. The resident required extensive assistance of two staff for bed mobility and transfers, and supervision of one for eating. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, resident and staff interviews, and policy review the facility failed to provide proper incontinence care to minimize the risk of cross-contamination and prevent the risk and occurrence of a urinary tract infection for 3 and 3 residents observed for incontinence care (Resident #31, #52, and #1). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of a non-traumatic brain dysfunction, cerebrovascular accident (stroke), and dementia. The MDS documented the resident had a brief interview of mental status (BIMS) score of 7, indicating severely impaired cognition. The MDS indicated the resident had incontinence and required substantial to maximum assistance for toilet transfer and dependent for toileting hygiene. The Care Plan initiated and revised on 10/25/23 revealed the resident had an ADL (activities of daily living) self-care performance deficit related to dementia and impaired cognition. The Care Plan directed…

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, observation, staff interviews, and facility policy review, the facility staff failed to ensure a physician's order for oxygen use and failed to ensure oxygen equipment maintained for one of two residents reviewed for oxygen use (Resident #52). The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had a history of COVID-19. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicated cognition intact. The MDS revealed oxygen not marked under section O /special treatments. The Care Plan revealed the resident had oxygen therapy related to a respiratory illness added to the Care Plan on 10/23/23 (during the survey week). The order summary revealed a verbal order entered on 10/23/23 (during the survey week) for oxygen at 1-3 liters per nasal canula as needed, and change oxygen tubing every Sunday on the night shift. The Progress Notes revealed: a. On 9/26/23 at…

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 interview and facility policy review, the facility failed to assure a medication error rate of less than 5%. The facility reported a census of 81 residents. Findings include: During observation on 10/24/23 medication pass was observed for a total of 5 residents, including Resident #26, Resident #28, and Resident #33. A total of 36 medications were observed being administered. Four errors were observed, calculating a medication error rate of 11.11%. Resident #33 was given her morning medications by Staff I, Certified Medication Aide (CMA) at 8:08 AM. She received a total of 11 oral medications. Two of those medications, Amlodipine 10 mg, and Lisinopril 40 mg (both are blood pressure pills) had instructions to hold the medication if the resident had a systolic blood pressure of less than 100 mm Hg (millimeters of mercury) or a heart rate of less than 55 beats per minute. Staff I did not assess the blood pressure or the heart rate of of Resident #33 prior to administering either of the medications. Resident #28 was given his morning…

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, and staff interview, the facility failed to assure residents in the facility to be free of significant medication errors. The facility reported a census of 81 residents. Findings include: During observation on 10/24/23 medication pass was observed for Resident #33. Resident #33 was given her morning medications by Staff I, Certified Medication Aide (CMA) at 8:08 AM. She received a total of 11 oral medications. Two of those medications, Amlodipine 10 mg, and Lisinopril 40 mg (both are blood pressure pills) had instructions to hold the medication if the resident had a systolic blood pressure of less than 100 mm Hg (millimeters of mercury) or a heart rate of less than 55 beats per minute. Staff I did not assess the blood pressure or the heart rate of Resident #33 prior to administering the medication. Review of Resident #33's Blood Pressure Summary and Pulse Summary revealed her blood pressure and pulse had been checked twice in August of 2023, twice in September of 2023, and as of the observation date of 10/24/23, her blood pressure had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interview, and facility policy review, the facility staff failed to change gloves and sanitize hands during cares, and failed to provide a sanitary environment and maintain infection control practices to prevent the potential spread of infection or disease for 3 of 19 residents sampled (Resident #52, #6, #35). The facility also failed to properly disinfect a glucometer after resident use for 1 of 2 observations. The facility reported a census of 81 residents. Findings included: 1. During an observation on 10/24/23 11:17 AM, Staff A, Certified Medication Aide (CMA) completed a blood glucose check for 1 resident and returned the glucometer (blood glucose monitor) to the medication storage cart. During an interview with Staff A, CMA, she revealed she used alcohol pads for disinfecting the glucometer. During an interview with Staff B, Licensed Practical Nurse (LPN), she confirmed alcohol pads were used to disinfect the glucometer which was shared…

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.