Greater Southside Health and Rehabilitation

Based on confidential resident interviews, family interviews, staff interviews, clinical record review, and facility policy review, the facility failed to provide appropriate staffing to meet residents needs. The facility reported a census of 70. Findings include: During a confidential resident interview on 8/25/25 at 11:30 AM, the resident reported he had noticed staff were not getting residents who sat at the assist table up for supper. During the supper meal, only one or two residents were at the assist table, but during the breakfast and lunch meals there were more residents seated at the assist table. The resident reported staff came into the room and shut the call light off, and staff got mad at the resident if he pressed the call light again. The resident reported there had been times when there were only one CNA working upstairs and one CNA working downstairs, which isn't enough to care for all of the residents at the facility. According the the MDS, the resident had a documented BIMS of 15, indicating intact cognition. In an interview 8/25/25 at 8:08 AM, Staff F, LPN,…

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 ensure a resident's buttocks was appropriately covered in order to maintain the resident's dignity for one of sixteen residents sampled (Residents #15). The facility reported a census of 70 residents.Findings include:The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had diagnoses of severe intellectual disability and schizoaffective disorder. The MDS recorded the resident had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated the resident required partial to moderate assistance for lower body dressing. The Care Plan revised 5/22/25 revealed the resident required assistance with Activities of Daily Living (ADL's). The Care Plan directed staff to provide assistance of one for dressing. During observation on 8/25/25 at 12:04 PM, Resident #15 sat in a chair by a table in the upper dining room with her buttocks fully exposed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and policy review the facility failed to administer treatments and perform dressing changes as ordered by the physician for one of four residents reviewed (Resident #11). The facility reported a census of 70 residents.Findings include: The Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a Stage 3 pressure ulcer on the left ankle, one Stage 1 pressure ulcer and one unstageable pressure ulcer. The MDS recorded the resident required application of nonsurgical dressings and medications for skin treatments. The Care Plan revised 5/23/25 revealed the resident had impaired skin integrity related to wounds on her left inner ankle and coccyx, and also had a history of infections. The care plan directed staff to administer treatments as ordered. The Care Plan lacked information about a wound to the right foot. The Order Summary Report dated 8/27/25 revealed an order to cleanse the right lateral foot wound…

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 direct observation, clinical record review, staff interview, and facility policy review, the facility failed to provide appropriate infection control practices in the form of enhanced barrier precautions when required for 3 of 5 individual reviewed (Resident's #9, #11, #14). The facility reported a census of 70. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #14, dated 07/17/2025, documented the residents Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. It documented the following relevant diagnoses: Septicemia (Blood infection), Hip fracture, Cerebrovascular Accident (Stroke), Paraplegia (Paralysis of the legs), Traumatic Brain Injury, Need for Assistance with personal Cares, Pressure ulcer of the right ankle. The MDS documented that the resident was dependent on staff for toileting hygiene, personal hygiene, lower body dressing, and putting on/taking off footwear.The Care Plan for Resident #14, last revised 08/14/2025, documented the resident's…

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

Based on observations, staff interview, and policy review, the facility failed to ensure the lunch menu and meal met the nutritional needs and preferences for 7 out of 68 resident lunch trays prepared. The facility reported a census of 72. Findings include: During on observation on 6/4/25 at 10:30 AM, Staff L, Cook, pureed 2 pork steaks for lunch service. Staff L confirmed the facility had 2 residents on a puree diet. The puree food was placed in a steamtable pan and into the over for reheat until service. During the observation, Staff L did not measure out the final volume of the puree meat before placing into the steam table pan. A Puree Diet Portion Sizes/Scoops chart was laying on the table where the puree food was prepared. Staff L reported the Diet Spreadsheet listed the use of a #8 scooper size for the puree pork. During a lunch service on 6/4/25 from 11:15 AM to 12:45 PM, the following was observed: a. 1 resident did not receive a Magic Cup supplement which was highlight on the lunch ticket b. 1 resident received a Mighty Shake supplement instead of a Magic Cup which was…

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

Based on observations, staff interviews, and policy review, the dietary staff failed to maintain clean and sanitary conditions in the kitchen, failed to label and store food items in the kitchen in order to maintain food quality and reduce the risk of food-borne illness, and failed to thaw food to reduce the risk of food-borne illness. The facility reported a census of 72 residents. Findings include: 1. Initial tour of the kitchen on 06/02/25 starting at 11:15 AM revealed the following: a. A large trash barrel with the lid partially off and several broken down cardboard boxes blocked the left door to the Arctic Air freezer. The freezer door handle felt sticky and had dried liquid spillage and crumbs of food lying on the bottom of the freezer. b. One package of what appeared to be blueberries unlabeled and undated. c. The drawer handle with utensils (scoops) inside had a sticky residue. d. A bulk container of sugar had a scoop lying on top of the sugar and the handle of the scoop sat in the sugar. e. A bulk container of flour had no date listed. f. A bulk container of breadcrumbs 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 4. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had diagnoses of neurogenic bladder, diabetes, and renal insufficiency. The MDS revealed the resident had a indwelling catheter. The care plan initiated 5/25/25 revealed the resident had a Foley catheter due to neurogenic bladder. The care plan directed staff to use enhanced barrier precautions (EBP). The Order Summary revealed orders for catheter care ordered on 05/28/25 and EBP's ordered on 05/14/25. Gown and gloves were required for residents with a indwelling medical device and during high-contact care activities. During observation on 06/02/25 at 01:31 PM, an EBP sign hung on the door to the resident's room. During observation on 06/05/25 at 08:00 AM, an EBP sign hung on the door to the resident's room. The EBP sign indicated a gown and gloves should be worn during high-contact activity and when catheter care performed. Staff F, certified nursing assistant (CNA) washed his hands, donned a pair of gloves, and drained Resident #54's…

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 Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had diagnoses that included metabolic encephalopathy, diabetes, hypertension (high blood pressure), and respiratory failure. The Care Plan revised [DATE] revealed the resident desired a full code status or DNR status per the IPOST (Iowa Physician's Orders for Scope of Treatment) form. The staff directives included to refer to the IPOST form on file and review the advanced directives routinely at the care conferences and PRN (as needed). The Electronic Medical Health Record (EHR) physician's orders revealed Resident #30's code status as a Full Code. The order was created on [DATE] and listed as active. The Order Summary Report revealed a prescriber's active order for a full code ordered on [DATE]. The IPOST signed by the Nurse Practitioner and Resident #30 on [DATE] revealed a DNR/do not attempt resuscitation status. The IPOST binder kept at the nurse's station revealed the IPOST order signed by the Nurse Practitioner and Resident #30 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 clinical record review, staff interview, and policy review, the facility failed to ensure timely follow-up for the initiation of an as-needed (PRN) use of a psychotropic drug for 1 of 5 residents reviewed for unnecessary medications (Resident #37). The facility reported a census of 72. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 4/16/25 revealed Resident #37 unable to complete the Brief Interview for Mental Status and is severely impaired for daily decision-making. Diagnoses on the MDS include aphasia (communication disorder), autistic disorder, and profound intellectual disabilities. Resident #37 displayed behaviors not directed towards other, such as yelling/screaming. The MDS documented the use of antipsychotic, antianxiety, and antidepressant medications which are all types of psychotropic medications. The Care Plan, which was last updated on 5/13/25, included the use of an antipsychotic mediation related to explosive disorder and an antianxiety medication related to mood disorder/autism. Review of Physicians Orders for Resident #37…

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

Based on clinical record review, staff interview, and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to accurately reflect the status of 3 of 3 residents in the Minimum Data Set (MDS) Assessments (Resident #11, #13, #37). The facility reported a census of 72 residents. Findings include: 1. The Pre-admission Screening and Resident Review (PASRR) of Resident #11, dated 7/30/24, identified the resident to require PASRR Level II Services. (Considered by the State Level II process to have a serious mental illness and/or intellectual disability or a related condition). The PASRR identified the Resident to have diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder and identified symptoms the resident commonly expressed including being easily upset, not having desire to eat, having trouble sleeping, worry, anxiety, not wanting to be around others and having a passive death wish. The PASRR identified specialized services the facility needed to provide to the resident while remaining in the nursing facility included ongoing…

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

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure completion of a resident's baseline Care Plan within 48 hours of admission for 1 of 2 residents reviewed with an admission date within the past 30 days (Resident #223). The facility reported a census of 72. Findings include: The admission Minimum Data Set (MDS) Assessment completed on 6/5/25 documented Resident #223's facility admission date as 5/30/25. The Brief Interview for Mental Status score was 14, indicating intact cognition. Diagnoses on the MDS include anemia, atrial fibrillation, non-Alzheimer's dementia, and unsteadiness on feet (with one fall in the last month prior to facility admission). The facility document Therapy to Nursing Communication Form, dated 5/30/25, indicated Resident #223 was an assist of 2 staff members for stand-pivot transfers, an assist of 2 staff members for toileting (to and from commode and wheelchair), and an assist of 1 staff member to utilize a manual wheelchair. The Initial Care Plan-V2.0-V3, located in the Electronic Health Record, showed 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 record review, observations, resident and staff interviews, and policy review the facility failed to carry out therapy recommendations and provide restorative exercises for 1 of 2 residents reviewed for rehabilitation services and/or limited range of motion (Resident #30). The facility reported a census of 72 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had diagnoses of arthritis and muscle weakness. The MDS indicated the resident had independence with toileting and transfers. The MDS revealed the resident began Physical Therapy services (PT) on 6/21/24 and Occupational Therapy (OT) services 8/7/24. The MDS indicated the resident had Restorative Nursing Program (RNP) for zero (0) days during the look-back period. The MDS assessment dated [DATE] revealed Resident #30 had unsteadiness on his feet and muscle weakness. The MDS revealed the resident had impaired range of motion (ROM) to the upper extremity on one side. The MDS indicated 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, staff interviews, and policy review, the facility failed to offer a morning meal or snack to a resident (Resident #8). The facility reported a census of 72. The Minimum Data Set (MDS) Assessment completed on 3/21/25 revealed Resident #8 unable to complete the Brief Interview for Mental Status, is severely impaired for daily decision-making, and has long/short term memory problems. Diagnoses on the MDS include non-Alzheimer's dementia and malnutrition with weight loss. The MDS reported Resident #8 relies on staff for substantial eating assistance. The Care Plan, last revised on 5/19/25, outlined Resident #8 receives a puree diet with nectar-thick liquids. The Care Plan further documented the presence of an unstageable pressure injury to the coccyx as well as a stage 3 pressure injury to the left ankle. During an observation on 6/5/25 at approximately 9:35 AM, Resident #8 was sitting in the lower (downstairs) dining room with Staff M, Certified Nursing Aide. When asked, Staff M indicated the resident's breakfast tray had already been thrown out and was unable 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 observation, staff interview, clinical record review, and policy review, the facility failed to assure a medication error rate of less than 5%. Medication errors were observed for Resident #45 and Resident #11. A total of 27 ordered medications were reviewed with two errors, an error rate of 7%. The facility reported a census of 72 residents. Findings include: 1. On 6/4/25 at 8:54 am, at 7:59 am, Staff C, Certified Medication Aide (CMA) prepared a total of 2 medications for Resident #45. Among the medications observed, Staff C prepared one tablet of Vitamin D, 25 micrograms (mcg). 2. Staff A next prepared medications for Resident #11. She was witnessed preparing and administering ten medications for Resident #11 including Atenolol 50 milligrams (mg), a blood pressure medication. When reconciling the observed medication pass against the orders for Resident #45, it was noted the resident's order was for Vitamin D3, 25 mcg rather than the Vitamin D the resident received. It was also noted for Resident #11 that the order for the resident's Atenolol included parameters to not…

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, observations, resident and staff interview, and facility policy review, the facility failed to securely store medications for 1 of 7 residents observed during medication administration (Resident #34). The facility reported a census of 72 residents. Findings include: The Minimum Data Set (MDS) of Resident #34 dated 4/3/25 identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The Care Plan of Resident #34 identified Resident #34 had diagnoses of emphysema and Chronic Obstructive Pulmonary Disease (COPD) related to smoking (dated 8/1/24). It directed the staff to give aerosol or bronchial dilators as ordered. The Care Plan failed to identify the resident was able to self administer any medications. On 6/2/25 at 2:04 pm, the State Surveyor was observing Staff B, Licensed Practical Nurse (LPN) administer tube feeding to Resident #33, who shares a room with Resident #34. During the observation, the nebulizer machine on Resident #34's side of the room was heard to be turned on, with no nursing staff present on that…

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, staff interview, and policy review, the facility failed to ensure a resident was served the correct food texture for 1 of 2 residents on a puree diet (Resident #47). The facility reported a census of 72. The Minimum Data Set (MDS) Assessment completed on 5/7/25 revealed Resident#47 with a Brief Interview for Mental Status score of 10, indicating a moderate cognitive impairment. The MDS stated Resident #47 requires maximum eating assistance. Medical diagnoses listed in the electronic health record include dementia and dysphagia (swallowing difficulties). Review of Physician Orders noted Resident #47 on a puree texture diet with moderately thick liquids as of 3/14/25. During the lunch service observation on 6/4/25, Resident #47 was provided a lunch plate consisting of puree barbeque pork steak, puree baked beans, and mashed potatoes. A short time later, an unknown staff member set a bowl of regular textured potato salad in front of Resident #47. During an interview on 6/10/25 at 10:00 AM, the Certified Dietary Manager acknowledged Resident #47 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.

Based on clinical record review, family and staff interviews, and facility policy review, the facility failed to verify patient identifiers before sending transfer paperwork, resulting in the receiving facility obtaining inaccurate medical records for one of three residents reviewed for discharge planning (Res #172). The facility reported a census of 72 residents. Findings include: On 6/3/25 at 9:30 am, a family member of Resident #172 stated the facility sent the incorrect paperwork for her family member to another facility where Resident #172 transferred to. The family member stated when Resident #172 transferred to the other facility, orders were placed incorrectly and the resident did not receive her own medications due to this error for approximately two weeks. She was prescribed psychotropic medications, but did not receive them as ordered, which resulted in a hospitalization related to her mental health. The Discharge Summary for Resident #172, dated 4/17/25, documented the resident's date of birth as 5/12/1954. The Reason for discharge was documented as discharging 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 staff interview, clinical record review, and facility policy review, the facility failed to identify and report ongoing abnormal vital signs, outside of normal ranges, for 2 of 2 residents (Resident #1 and Resident #2). The facility further failed to complete respiratory assessment (Resident #1) when identified as short of breath on exertion for 5 out of 10 days reviewed. The facility reported a census of 68 residents. Findings include: 1. The admission Assessment, dated 4/11/25, revealed Resident #1 had been alert, confused, oriented to person and place on admission. Resident #1's apical pulse identified as regular in rhythm and resident denied cardiovascular concerns. admission Assessment revealed Resident #1 had no pulmonary diagnoses, respirations were normal without shortness of breath. Resident #1 noted to have contractures and weakness of bilateral upper and lower extremities, and utilized a wheelchair for mobility. The Baseline Care Plan, initiated 4/12/25, revealed Resident #1 at risk 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 record review, observations, resident interview, visitor interview, staff interview, and policy review the facility to treat residents in a dignified, respectful manner by entering resident rooms without announcement or knocking and by not ensuring clothing appropriate to the weather conditions for 3 of 10 residents reviewed. (R#1, R #2, R#4). The facility reported a census of 70. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 listed diagnoses of heart disease, cancer, and end stage renal disease depression. The MDS documented the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan focus initiated 11/27/24 documented resident #2 wishes to be long term placement, in addition Resident #2 had self-care deficits. Interventions included to allow resident to make decisions about treatment regime and to provide sense of control. On 3/18/25 at 9:50 AM observed Activity Department, (AD) Staff A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review, personnel file review, resident interview, staff interview, and facility policy review, the facility failed to protect 1 of 3 residents (Resident #3) reviewed from financial abuse. The facility reported a census of 70 residents. Findings include: Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. The MDS reflected Resident #3 diagnosis Parkinson's disease without dyskinesia, dysphagia, atherosclerotic heart disease, hyperlipidemia, essential hypertension, abnormal gait and mobility, muscle wasting and atrophy, and weakness. The MDS further documented Resident #3 required staff assistance for performing most activities of daily living. A facility reported incident dated 1/20/25 documented the following: on January 20, 2025, at approximately 2:45 PM, the facility was alerted to an isolated incident regarding the misappropriation of property…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, resident interview and policy review, the facility failed to ensure before and after dialysis assessments were completed for 1 of 1 resident reviewed on dialysis (Resident #2). The facility reported a census of 70 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 revealed diagnosis of end stage renal disease and received dialysis. The Brief Interview for Mental Status (BIMS) scored 15 out of 15 indicating no cognitive impairment. The Care Plan for Resident #2 initiated 9/18/24 documented Resident #2 needed dialysis related to renal failure. Staff directed to encourage resident to go for the scheduled dialysis appointments, to check the fistula (site for dialysis) daily, to obtain vital signs and weight, report significant changes in pulse, respirations and blood pressure immediately, to monitor, document and report to the provider signs any symptoms of renal insufficiency. During an interview 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 observation, staff interviews, resident interviews and policy review, the facility failed to provide a proper functioning call system to allow resident to staff communication for 1 of 5 residents reviewed. (Resident #1). The facility reported a census of 70. Findings include: The Annual Minimum Data Set (MDS) for Resident #1 dated 12/12/24 listed diagnoses included traumatic brain injury, heart disease, respiratory failure, diabetes, renal disease, depression, schizophrenia, acquired absence of right and left leg above knees. The resident was coded needed substantial/maximus assistance with transferring from bed or chair, for dressing lower body bathing and putting footwear. MDS section for Brief Interview of Mental Status (BIMS) scored 15 out of 15 which indicated intact cognition. The Care Plan initiated 8/2/24 for Resident #1 documented self-care performance deficit with intervention to encourage to use bell to call for assistance. On 3/18/25 at 10:30 AM Resident #1 relayed had pulled cord was waiting for staff, not sure how long ago had pulled the call card. Resident #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, hospital documentation review, resident, staff interviews and policy review the facility failed to assure that 1 of 1 resident (Resident #1) that received dialysis treatments, was provided with arrangements to and from the dialysis facility of his choice. The facility reported a census of 59 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 7/16/24 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS listed the following diagnoses for him: end stage renal disease, atrial fibrillation, coronary artery disease, and diabetes mellitus. A Care Plan Focus Area with a revision date of 9/18/2024 documented Resident #1 needed dialysis related to his renal failure. Staff are instructed to encourage the resident to go for the scheduled dialysis appointments. The hospital provided a document titled Discharge Summary with an admission date of 9/22/24 and discharge date of 10/2/24. The summary included 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.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access for two of two laptops reviewed in common areas. The facility reported a census of 67 residents. Findings include: On 9/23/24 at 9:10 am, the Side 2 (200 resident hall) medication cart was observed unlocked and resident information was visible on the laptop screen. There was no staff present. Staff A, Certified Medication Aide (CMA) stated he left the cart unlocked and the laptop open by mistake. On 9/24/24 at 12:08 PM, a medication cart was observed unlocked and 12 residents ' information was visible on the laptop screen. There were 8 residents sitting in the dining room and no medication authorized staff was present. Staff B, Certified Medication Aide (CMA) stated it is not customary to leave the laptop with resident information and the medication cart unlocked when staff are away from the cart. A document titled Safeguards for PHI (Protected Health Information) dated January 2017 directed staff to store all documents containing PHI in 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, resident, family, and staff interview, and policy review the facility failed to ensure the resident's representative rights were met for 1 of 3 residents reviewed. (Resident#10). The facility identified a census of 67 residents. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #10 dated 9/12/24 revealed a Brief Interview for Mental Status (BIMS) score could not be obtained but indicated the resident was rarely or never understood. It included diagnoses of anemia, hyponatremia (low blood sodium), non-Alzheimer's Dementia, Transient Ischemic Attack (TIA-brief blockage of blood flow to the brain), metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood), and electrolyte imbalances. It revealed the resident was usually understood with difficulty communicating some words or finishing thoughts and was dependent for all levels of Activities of Daily Living (ADLs). The Care Plan indicated the resident desired to be a full-code and was dependent on staff for cognitive stimulation. It also directed staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family and staff interview, and policy review the facility failed to notify a resident family/representative of a medication change for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 67 residents. Findings Include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 carried the diagnoses of congestive heart failure, diabetes, mitral and aortic valve stenosis and venous insufficiency. The MDS indicated the resident's Brief Interview for Mental Status (BIMS) score was 99 indicating the resident was unable to complete the interview and had severely impaired decision making. Resident #1 was dependent on staff for toileting, bathing, personal hygiene and transfers and required set up assistance with eating. The resident received anti anxiety, antidepressant, diuretic, opioid, and hypoglycemic medications during the observation period. She received oxygen therapy and was under hospice care. The Care Plan dated 8/5/24 indicated…

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, record review, staff interview and policy review, the facility failed to ensure physician orders were followed and documented appropriately and accurately for 2 of 4 residents reviewed (Resident #2 and #8). The facility reported a census of 67 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #8 had diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure, obstructive sleep apnea, schizoaffective disorder, anxiety and morbid obesity. The MDS indicated the resident's Brief Interview for Mental Status (BIMS) score was 10 which indicated moderate cognitive impairment. The resident required set up or clean up assistance with eating, toileting, and personal hygiene, moderate staff assistance with bathing and was independent with transfers. Resident #8 experienced shortness of breath with exertion, when sitting at rest and when lying flat and utilized oxygen therapy. The Medication Administration…

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

Based on clinical record review, staff interview, and policy review the facility failed to ensure physician's orders were followed for 2 of 3 residents reviewed (#2, #10). The facility identified a census of 67 residents. Findings include: 1) The Quarterly Minimum Data Set (MDS) for Resident #10 dated 9/12/24 revealed a Brief Interview for Mental Status (BIMS) score could not be obtained but indicated the resident was rarely or never understood. It included diagnoses of anemia, hyponatremia (low blood sodium), non-Alzheimer's Dementia, Transient Ischemic Attack (TIA-brief blockage of blood flow to the brain), metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood), and electrolyte imbalances. It revealed the resident was usually understood with difficulty communicating some words or finishing thoughts and was dependent for all levels of Activities of Daily Living (ADLs). The Care Plan indicated the resident desired to be a full-code and was dependent on staff for cognitive stimulation. It also directed staff to engage the resident in simple,…

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 interview, and policy review, the facility failed to provide treatment and services to promote the healing of a pressure ulcer for 1 of 3 residents reviewed (#4). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated 8/05/24 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of neurogenic bladder (uncontrolled bladder due to nerve damage), hip and other fractures, traumatic brain injury (TBI), and a pressure ulcer. It also revealed the resident required setup assistance with eating, supervision with oral and personal hygiene, moderate assistance with upper body dressing, and was dependent with all other activities of daily living (ADLs). It further indicated he received nonsurgical dressings. The Care Plan dated 9/08/24 directed staff to change the wound vac to the right ischium (the lower back part of the hip)…

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, staff interview and policy review, the facility failed to ensure oxygen was available to a resident requiring the use of oxygen for 1 of 3 residents reviewed (Resident #9). The facility reported a census of 67 residents. Findings include: 1) Observation on 9/26/24 at 2:40 PM revealed the Resident #9 resting in wheelchair in lounge, no date on tubing, portable oxygen tank noted completely empty and on 3 liters. The Staff E, Certified Medication Aide (CMA) assessed the pulse ox-noted 85-89%-oxygen tank is empty, checked the nasal cannula for air flow-none noted, looked at the gauge on the portable oxygen tank, noted the tank is empty, asked staff to get a portable oxygen tank, the Assistant Director of Nursing (ADON) obtained the portable oxygen tank, noted the oxygen tank empty, and proceed to switch the tanks, and assessed the pulse ox-noted 95% on 3 liters. Observation on 9/30/24 at 11:26 AM revealed the Resident #9 sitting in wheelchair with visitor in lounge, noted portable oxygen tank gauge at beginning of red-revealed need for refill tank,…

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 and family interviews, staff interviews, record review, and policy review, the facility failed to maintain competent staff to appropriately perform an enema on a resident (#5) and provide wound vacuum care for 1 resident (#4). The facility reported a census of 67 residents. Findings include: 1) On 9/23/24 at 12:30 pm, Resident #10 reported Staff F, Licensed Practical Nurse (LPN) performed his bowel enema roughly on 9/18/24 and he experienced rectal bleeding afterward. On 9/23/24 at 1:30 pm, the Assistant Director of Nursing (ADON) performed the resident's enema. He was observed providing digital anal stimulation prior to inserting the enema wand into the resident's rectum. On 9/23/24 at 2:00 pm, the resident's relative stated she informed Staff F that she was performing the procedure incorrectly when she noticed Staff F attempted to insert the enema wand into Resident #10's rectum without the resident properly positioned in the shower chair and no visual confirmation of rectum location. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and policy review, the facility failed to properly secure medications from unauthorized access for two of two medication carts observed. The facility reported a census of 67 residents. Findings include: 1) On 9/24/24 at 9:10 am, the Side 2 (200 resident hall) medication cart was observed unlocked with no staff present. Staff A, Certified Medication Aide (CMA) stated he left the cart unlocked by mistake. 2) On 9/24/24 at 12:08 PM, the Side 1 (100 resident hall) medication cart was observed unlocked. There were 8 residents sitting in the dining room and no medication authorized staff was present. Staff B, Certified Medication Aide (CMA) stated it is not customary to leave the medication cart unlocked when staff are away from the cart. A policy titled Medication & Treatment Carts revised 8/01/24 indicated the medication and treatment carts are to be locked at all times when not in use. It also directed staff the cart must remain in line of sight when it is not locked and 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, staff interview and policy review, the facility failed to refer two residents (Residents #29 and #36) with a Level I Preadmission Screening and Resident Review (PASRR) with a previously unknown serious mental disorder for evaluation of a Level II PASRR at the time the diagnosis was known to the facility for 2 of 4 residents reviewed for PASRR. The facility reported a census of 60. Findings include: 1. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #29 had a Brief Interview for Mental Status (BIMS) of 11, which indicated moderate cognitive impairment. The MDS further documented the resident to have diagnoses to include traumatic brain dysfunction, non Alzheimer's dementia, anxiety disorder, depression, paranoid personality disorder and psychotic disorder. A Preadmission Screening and Resident Review (PASRR) for Level I dated 11/30/22, documented the primary diagnoses as anxiety disorder and depression. The PASRR documented the resident was on Lexapro. 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 family interview, staff interview, and facility training material the facility failed to include the resident representative in the care plan participation conference for one (Resident #33) of fourteen residents reviewed. The facility reported a census of 60 residents. Findings include: 1. A admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #33, documented resident admitted on [DATE] and a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The Clinical Resident Profile for Resident #33 revealed a family member as Power of Attorney (POA) for care, financial and healthcare for the resident, as well as the care conference person and responsible party. During an interview 7/8/24 at 2:13 PM, the family member who is POA, responsible party and care conference person reported never being invited to or attending a care conference for Resident #33 to discuss plan of care. Review of the Electronic Health Record (EHR) for the Resident #33 lacked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, staff interview, record review and policy review, the facility failed to provide necessary services to maintain grooming for nail care for 2 of 2 residents (Residents #33 and #57) reviewed for Activities of Daily Living (ADL). The facility reported a census of 60 residents. Findings include: 1. A admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #33, documented a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS further documented the resident had diagnoses to include progressive neurological conditions, osteoporosis, Alzheimer's disease and non-Alzheimer's dementia. The Care Plan for Resident #33, with a revision date of 6/11/24, documented under the focus area an ADL self-care performance deficit related to dementia and limited mobility. The intervention and task section instructed staff to offer bathing/showering twice weekly, and as necessary, check nail length and trim 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, policy review, and staff interview, the facility failed to ensure bathroom surfaces were clean and tile in good repair for 4 of 4 resident bathrooms observed. The facility reported a census of 59 residents. Findings include: Observation of sampled resident bathrooms revealed the following concerns: On 5/30/24 at 9:03 a.m. the bathroom of room [ROOM NUMBER], occupied by Resident #3, was missing a tile on the back wall and had a black substance covering the edges of the tiles. On 5/30/24 at 9:10 a.m., the bathroom of room [ROOM NUMBER], occupied by Resident's #4 and #6, had a missing tile on the back wall with a black substance on the walls and built-up in the corners of the room. On 5/30/24 at 9:30 a.m., the bathroom of room [ROOM NUMBER], occupied by Resident #1 had a brown substance on the hinges of the toilet seat and on the outside of the toilet. On 6/3/24 at 3:54 p.m., the Director of Nursing stated bathrooms should be free of black substances and tiles should be in good shape. 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 clinical record review, policy review, and staff and resident interview, the facility failed to notify the family of a resident's change in condition for 1 of 3 residents reviewed for assessment(Resident #1). The facility reported a census of 59 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 4/16/24, listed diagnoses for Resident #1 (R#1) which included acute respiratory failure with hypoxia (a low amount of oxygen in the blood), heart failure, and diabetes (a disease which caused abnormal blood sugars). The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 4/16/24 11:12 a.m. Nurses Note stated the resident reported that yesterday he bumped his shoulder while out on transport and was now having pain in his right shoulder. The facility lacked documentation of resident representative notification of the incident. On 5/30/24 at 8:29 a.m., via phone, the resident's representative stated R#1 was in the van and the driver stopped suddenly, and the brake did not work so…

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, policy review, and staff and resident interview, the facility failed to follow professional standards by failing to carry out leg wraps as ordered, failing to ensure a resident received a meal in a timely manner after receiving insulin (an injectable medication used to treat diabetes), and failing to ensure the provision of audiology (the medical specialty which treated disorders of the ear) services for 1 of 3 residents reviewed for professional standards (Resident #1). The facility reported a census of 59 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/16/24, listed diagnoses for Resident #1 which included acute respiratory failure with hypoxia (a low amount of oxygen in the blood), heart failure, and diabetes (a disease which caused alterations in blood sugars). The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. a. An 11/27/23 Care Plan entry stated the resident had the potential for impaired circulation and dependent edema(swelling…

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, policy review, and staff and resident interview, the facility failed to ensure a resident was secured in a van during transport causing the resident to bump his shoulder during the ride for 1 of 3 resident's reviewed for supervision(Resident #1). The facility reported a census of 59 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/16/24, listed diagnoses for Resident #1 which included acute respiratory failure with hypoxia (a low amount of oxygen in the blood), heart failure, and diabetes (a disease which caused abnormal blood sugars). The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 4/16/24 Nurses Note stated the resident reported that yesterday he bumped his shoulder while out on transport and was now having pain in his right shoulder. On 5/30/24 at 8:29 a.m., via phone, the resident's representative stated he was in the van and the driver stopped suddenly and the brake did not work so he went forward suddenly because he was not…

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, resident and staff interviews, record review and policy review, the facility failed to provide safe mechanical lift transfers for 2 of 3 residents reviewed (Residents #1 and #5). The facility failed to transfer residents safely by locking the lift wheels while raising the resident. The mechanical lift recommendations and warning sign posted on the lift stated that the wheels must remain unlocked during transfers. If the wheels are in the locked position it can affect stabilization during the lift procedure. The facility identified a census of 62 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS indicated Resident #1 was dependent for transfer. The MDS included diagnoses of bipolar disorder, Schizophrenia, dependence on wheelchair, abnormalities of gait and mobility. The Care Plan initiated 5/13/16 and a revision date of 4/12/23,…

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, facility policy review resident interview and staff interview, the facility failed to follow physician orders as directed for 1 of 4 residents reviewed (Resident #4). Medications for Resident #4 were omitted without physician notification. The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 12/21/23 included diagnoses of diabetes mellitus, non-Alzheimer's dementia, depression, bipolar disorder, and obstructive sleep apnea. The MDS documented the resident required moderate assistance for toileting and supervision for bed mobility and transfers, and set up assistance for eating. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The Care Plan dated 12/20/21 with a revision dated of 7/7/23, revealed a focus area for diabetes mellitus and an intervention to administer diabetes medication as ordered by the doctor and to monitor/document for side effects and effectiveness. Review of the Medication Administration Record (MAR) 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, observations, resident interview and staff interviews, the facility failed to accommodate residents needs with assurance of accessibility to call lights within resident's reach and provision of appropriate and adaptive equipment for 1 of 1 residents reviewed (Resident #33). The facility reported a census of 59. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #33 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. The MDS reflected diagnoses including medically complex conditions, aphasia and Schizophrenia. The MDS coded a functional limitation in range of motion on both sides of the upper extremity (shoulder, elbow, wrist, hand). The Care Plan for Resident #33, revised 7/15/22 reflected a focus area of activities of daily living (ADL). The focus area documented Resident #33 had an ADL self care performance deficit related to stroke and quadriplegia. The Care Plan directed 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 clinical record review and staff interview, the facility failed to notify the Long Term Care Ombudsman for 1 of 1 residents who transferred to the hospital (Resident #47). The facility reported a census of 59 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #47 documented diagnoses to include medically complex conditions, anemia and cirrhosis of the liver. The MDS documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS dated [DATE] documented Resident #47 had an unplanned discharge to an acute care hospital with a return anticipated. The MDS dated [DATE] documented Resident #47 re-entered the facility 8/14/23. The Progress Notes for Resident #47 revealed the resident transferred to the hospital on 7/24/23 and returned to the facility on 8/14/23. On 9/6/23 at 2:30 pm, the Administrator confirmed the facility did not notify the Ombudsman of the transfer to the hospital for Resident #47. 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 refer one of three residents (Resident #18) with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who had a possible serious Mental Disorder, Intellectual Disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination. The facility reported a census of 59. Findings include: The Minimum Data Set (MDS) for Resident #18, dated 6/23/23 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated cognition intact. The MDS documented diagnoses that included anxiety disorder, depression and schizophrenia/schizoaffective disorder. The Care Plan of Resident #18 identified focus areas of use of anti-anxiety, antidepressant and antipsychotic drugs due to schizoaffective disorder. These focus areas were dated 5/31/23. The PASRR dated 9/21/17 documented the resident had no diagnosis of schizophrenia or schizoaffective disorder. The Medical Diagnosis portion of the Electronic Health…

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

Based on clinical record review, staff interviews and facility policy review, the facility failed to revise the comprehensive care plan to accurately reflect status of 1 of 18 residents reviewed (Resident #18). The facility reported a census of 59. Findings include: The Minimum Data Set (MDS) for Resident #18, dated 6/23/23 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated cognition intact. The MDS documented diagnoses that included anxiety disorder, depression and schizophrenia/schizoaffective disorder. The Medical Diagnosis portion of the Electronic Health Record (EHR) documented the diagnosis of schizoaffective disorder was added as an active diagnosis on 4/8/19. The Care Plan of Resident #18, identified focus areas of using anti-anxiety, antidepressant and antipsycotic drugs due to schizoaffective disorder. These focus areas were dated 5/31/23. The Care Plan failed to have a focus area for mental illness to direct the staff of any specific needs to care for the resident's schizoaffective disorder. On 9/7/23 at 2:12 pm, 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, family interview and staff interviews the facility failed to provide restorative therapy to 1 of 3 residents reviewed for limited range of motion (Resident #43). Findings include: The Minimum Data Set (MDS) dated [DATE] of Resident #43 documented an admission date of 9/15/22. The MDS documented diagnoses that included stroke and hemiplegia (paralysis of one side of the body). The MDS revealed the resident totally dependent upon staff physical assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene. The MDS coded a functional limitation in range of motion (ROM) with impairment present on one side of the resident's body in both the upper and lower extremities. The MDS reflected the resident received no physical, occupational or restorative therapy. The Care Plan reflected a focus area of ADL (Activities of Daily Living) self-care performance deficit due to hemiplegia and stroke, dated 10/17/22. The Care Plan directed the resident to be…

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.