Rehabilitation Center of Des Moines

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to have clear direction for their staff regarding code status for 1 of 1 resident reviewed (Resident #2). The facility had a doctor's order for a full code which directed that in the event Resident #2's heart and respirations should stop, CPR (Cardiopulmonary Resuscitation)(Chest Percussions and rescue breathing) (Full Code) was to be performed. The IPOST (Iowa Physician's Orders for Scope of Treatment) for this resident directed that this resident was to be a DNR (Do Not Resuscitate) in the event Resident #2's heart and respirations should stop this resident was not to have chest percussions nor was he to have rescue breathing given to him. The facility reported a census of 72 residents. Findings include: A Care Plan for Resident #2 had a focus area initiated on [DATE], directed that Resident #2 desired to be a DNR per IPOST. The Goal was that Advanced Directives will be honored by staff. The intervention directed that the IPOST document…

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, interviews, and record and policy review, the facility failed to ensure safety risks were minimized for 1 of 1 resident observed (Resident #8). Resident #8 was observed being pushed in her wheelchair (w/c) by Staff F, Certified Nurse Aide (CNA) without her feet on w/c pedals. It was noted that the bottom of Resident #8's feet were skimming the floor while Staff F was pushing her. The facility reported a census of 72 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #8 included carpal tunnel syndrome bilateral upper limbs, repeated falls, and weakness. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognitive functioning. Resident #8 could wheel herself once seated in a manual wheelchair at least 50 feet and make 2 turns. It documented that this resident used a manual wheel chair and once seated she had the ability to wheel at least 150 feet in a corridor or similar space.…

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 family interview, and policy review, the facility failed to maintain infection control standards due to not wearing Personal E(PPE) of gown and gloves while providing high contact care activity for a resident required to be on Enhanced Barrier Precautions (EBP) (an infection control intervention requiring staff to wear designated PPE to reduce transmission of organisms for designated residents) for 3 (Resident #49, #119, and #219) of 3 residents reviewed and not completing proper hand hygiene with cares for 1 (Resident #52) of 1 reviewed. The facility reported a census of 66 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #119, dated 8/9/24, included diagnoses of osteomyelitis (bone infection) of vertebra, Stage 4 (full thickness of skin wound) pressure ulcer of right buttock, and septicemia (infection in blood) and documented the resident had a Foley catheter (tube to empty urine from the bladder) and colostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review, the facility failed to ensure dignity was provided, resident pulled to shower room backwards down the hall covered with only a blanket for 1 of 3 residents reviewed for dignity (Resident #51). The facility reported a census of 66 residents. Findings include: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. The MDS further documented the resident had diagnoses included traumatic brain injury, schizophrenia and bilateral lower leg amputation. The resident required substantial/maximal assistance with bathing. The Care Plan dated initiated 2/21/24 revealed a focus area for Resident #51 Activity of Daily Living (ADL) self-care performance deficits related to traumatic brain injury and double below knee amputation. Interventions included substantial/maximum assistance with bathing/showering 2 times a week and as necessary, dependent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and policy review, the facility failed to revise and update a comprehensive person-centered care plan for 2 of 21 residents reviewed (Residents #27 and #61). The facility reported a census of 66 residents. Findings include: 1. The Minimal Data Set (MDS) assessment dated [DATE] recorded Resident #27 had diagnoses including cancer, anemia, coronary artery disease, hypertension, renal insufficiency, obstructive uropathy, history of urinary tract infections, and diabetes. Other diagnoses verified by the primary care provider include chronic osteomyelitis (unspecified site), difficulty walking (not elsewhere classified), type 2 diabetes with diabetic polyneuropathy, and acquired absence of left leg below the knee amputation (BKA). The MDS documented Resident #27 does not have any type of a urinary catheter. Resident #27's Care Plan, with target completion date of 11/1/24, revealed inconsistent amputation sites and presence of a urinary catheter with 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 and staff interviews the facility failed to obtain follow-up blood work in the timeframe ordered by the Primary Care Provider (PCP) laboratory (Resident #49) and the resident was eventually hospitalized with 1 of 3 residents reviewed. The facility reported a census of 66 residents. Findings include: 1. The admission Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #49 could not complete the Brief Interview for Mental Status. Diagnoses on the MDS included: renal insufficiency/renal failure/or end stage renal disease, diabetes, aphasia, stroke, hemiplegia/hemiparesis, and respiratory failure. The MDS revealed the presence of a feeding tube and the resident received tracheostomy care. Laboratory blood work obtained on 8/6/24, revealed a low potassium level of 3.1 mEq/L (reference range 3.4-5.0mEq/L) and a sodium level of 142 (refence range of 135-15mEq/L). On 8/8/24, the PCP ordered a potassium supplement and to recheck labs in one week (8/13/24). The order was noted…

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, clinical record review and facility policy the facility failed to ensure specialist referral for 1 of 3 residents reviewed for referrals. Resident #38 complained of worsening vision. The facility reported a census of 66 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition. The MDS included resident diagnoses, heart and respiratory disease, non-Alzheimer's dementia, anxiety, depression, post-traumatic stress and depression. The Care Plan dated 4/2/22 identified Resident #38 medications included the following types psychoactive drugs, antidepressants, antipsychotics and antianxiety medications and directed to observe for side effects which included blurred vision. A Progress Note dated 6/27/23 from the Nurse Practitioner, Staff C documented, detailed exam included for vision, seen today as a new patient,…

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 ensure an emergency tracheostomy kit was at the resident's bedside for 1 of 3 residents reviewed (Resident #57). The facility reported a census of 66 residents. Findings include: The Annual Minimum Data Set (MDS) for Resident #57, dated 7/19/24, included diagnoses of anoxic brain damage (due lack of oxygen) and respiratory failure. The MDS documented resident was totally dependent on staff for all cares, had a tracheostomy (surgical opening in neck to provide for obstruction of breathing) and required oxygen. Observation on 10/14/24 at 11:54 AM, resident in room reclined in a wheelchair with a tracheostomy, with an oxygen (O2) mask over the tracheostomy, and O2 at 4.5 liters. No emergency tracheostomy kit available at the resident's bedside. Resident's Care Plan initiated 6/30/23, documented resident had a tracheostomy related to impaired breathing mechanics and intervention to keep a tracheostomy tube and obturator (medical device to hold tracheostomy tube in place) at bedside. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interviews, the facility failed to honor a resident's desire to be a Do Not Resuscitate(DNR) status by initiating cardiopulmonary resuscitation(CPR) for 1 of 4 residents(Resident #2) reviewed for advance directives(written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual was incapacitated). The facility reported a census of 65 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated [DATE], listed diagnoses for Resident #2 which included heart failure, pneumonia, and wound infection. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The MDS documented the resident had diagnoses including heart disease, diabetes, kidney disease, and respiratory failure. The facility policy Nursing Administration with subject Advanced Directives revised 6/2023,…

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 interviews, the facility failed to notify the resident's family of an increase in pain and the need for additional pain medication for 1 of 3 residents reviewed for a change in condition(Resident #1). The facility reported a census of 65 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 8/19/24, listed diagnoses for Resident #1 which included Alzheimer's disease, anxiety disorder, and depression. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15. The MDS documented the resident had diagnoses including Alzheimer's disease, arthritis, joint contracture, muscle weakness. The facility policy Notification, Physician or Responsible Party, dated 8/2007, stated the facility would inform the resident's family/responsible party when there was a significant change in the resident's physical status. A Care Plan entry, dated 5/2/23, stated the resident's had acute(short term)/chronic(long-term) pain. An 11/2/23 5:28 p.m. Secure Conversations entry stated the nurse…

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 resident and staff interviews, the facility failed to report an allegation of abuse to the State Agency within 2 hours for 1 of 1 residents reviewed for an allegation of abuse(Resident's #3). The facility reported a census of 65 residents. Findings include: The admission Minimum Data Set(MDS) assessment tool, dated 2/28/24, listed diagnoses for Resident #3 which included anxiety, depression, and psychotic disorder, and listed her Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. The facility policy Abuse: Prevention of and Prohibition Against, revised 12/20/23, stated all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator and the facility would notify the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations. The policy stated the facility would immediately remove the employee from the care of any resident and suspend the employee…

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 resident and staff interviews, the facility failed to separate an alleged perpetrator of abuse(Staff D) from other residents for 1 of 1 allegation of abuse reviewed(Resident's #3). The facility reported a census of 65 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 2/28/24, listed diagnoses for Resident #3 which included anxiety, depression, and psychotic disorder and listed her Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. The facility policy Abuse: Prevention of and Prohibition Against, revised 12/20/23, stated all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator and the facility would notify the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations. The policy stated the facility would immediately remove the employee from the care of any resident and suspend the employee during the pending of…

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

Based on observations, staff interview, clinical record review, and policy review the facility failed to implement appropriate infection control practices to prevent cross contamination. The facility reported a census of 68 residents. Findings include: 1. On 10/02/23 at 4:30 AM, the front cover of the linen cart near nurses' station was observed pulled up and sitting on top of rack exposing linen. A box of gloves, 2 packs of pericare wipes, and clear trash bags were stored on top of the cart. An isolation precautions sign was noted on two (2) resident rooms' door. The Personal Protective Equipment (PPE) cart, located outside of each room, did not contain isolation gowns. At 6:25 AM, the Assistant Director of Nursing (ADON) placed an isolation precautions sign on a resident's room door and stated it was for a positive COVID result obtained the previous week. There was no isolation precaution sign previously noted on the door. At 6:30 AM, Staff C, Certified Medication Aide (CMA), put on an isolation gown and wrapped the middle tie around his waist and did not tie the top string. He…

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. A Minimum Data Set (MDS) dated [DATE] for Resident #6, included diagnoses of Non-Alzheimer's Dementia and heart failure. The MDS identified the resident required extensive assistance of one staff for dressing. A continuous observation on 10/02/23 starting at 8:36 AM, Resident # 6 was in the dining room with six other residents. Resident #6 was sitting in a wheel chair, dressed in a shirt and with a blanket covering above knees to feet, with her bare upper thighs exposed. At 8:47 AM, a staff member pulled the blanket up to resident's waist and the blanket slid back down with exposure of upper thighs again and remained exposed until resident was taken to her room at 9:05 AM. An observation on 10/03/23 at 8:40 AM, Resident # 6 was in the dining room with staff assisting with dining. Resident was dressed in shirt and pants, no socks with bare feet exposed. An observation on 10/04/23 at 8:51 AM, Resident # 6 was in the dining room with staff assisting with dining. Resident was dressed in shirt and pants, no socks…

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, staff interview, and policy review the facility failed to report the results of an investigation for an allegation of abuse within 5 working days of the incident to the State Survey Agency for one of three residents reviewed (Resident #170). The facility reported a census of 68 residents. Findings included: The Minimum Data Set (MDS) assessment for Resident #170 dated 8/21/23, included diagnoses of Bipolar Disorder, Schizophrenia, and Anxiety Disorder. The MDS identified the resident needed limited assistance of one staff for dressing and toilet use, and was independent with bed mobility, transfers, personal hygiene, and locomotion. The MDS indicated the resident had a Brief Interview for Mental Status score of 14, indicating intact cognition for decision making. Facility Incident Report for Resident #170, dated 9/14/23 at 9:54 AM, documented the resident reported: nighttime CNAs (Certified Nurse Aide) are coming into her room at night to check for incontinence and are pulling back her sheets and grabbing her brief area without asking permission and also…

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 1 of 1 sampled resident with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who had a possible newly diagnosed serious Mental Disorder, Intellectual Disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination (Resident #17). The facility reported a census of 68 residents. Findings include: On 10/03/23 at 02:49 PM, Resident #17's medication list included Abilify prescribed for schizophrenia for hallucinations that began on 3/16/23. The Minimum Data Set (MDS) dated [DATE] included diagnoses of anxiety and Schizoaffective disorder and indicated the resident received antipsychotic, antidepressant, and antianxiety medications within the seven (7) day look-back period. It also identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The PASRR review dated 1/10/20 included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive care plan for 2 of 2 residents reviewed (Residents #7 & #54). The facility reported a census of 68 residents. Findings include: 1. On 10/02/23 at 6:25 AM, Resident #7 asked Staff C, Certified Medication Aide (CMA) for pain medication. Staff C told Resident #7 he would get it in a little bit. At 6:45 AM, Resident #7 asked another staff member for his pain medication. The staff member told Staff C that the resident requested pain medication. Staff C walked past the resident and told the resident he hadn't forgotten about him and would get his medication in a little bit. At 6:55 AM, Staff C began looking through the medication cart for another resident's medications. Resident #7 asked Staff C whose medications he was looking for. Staff C closed the medication drawer and opened the locked narcotic bin and got Resident #7's pain medication The Electronic Health Record (EHR) included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive care plan for 1 of 1 resident reviewed (Resident #17). The facility reported a census of 68 residents. Findings include: On 10/03/23 at 02:49 PM, Resident #17's medication list included Abilify prescribed for schizophrenia for hallucinations that began on 3/16/23. The Minimum Data Set (MDS) dated [DATE] included diagnoses of anxiety and Schizoaffective disorder and indicated the resident received antipsychotic, antidepressant, and antianxiety medications within the seven (7) day look-back period. It also identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of physician medication orders revealed a new order on 3/16/23 for Abilify for Schizophrenia with hallucinations. The Electronic Health Record (EHR) revealed a new diagnosis of schizoaffective disorder dated 8/21/23 and simultaneous removal of the schizophrenia diagnosis.…

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 ensure two storage closets were locked when not in use. The facility reported a census of 68 residents. Findings include: On 10/02/23 at 4:45 AM, a soiled utility storage room door was unlocked and a janitor's storage closet door had paper towel stuffed in the strike plate and prevented the door from latching. There were no staff members present and both storage closets contained unsecured chemicals used for disinfecting and cleaning surfaces. The unit housed multiple, independently ambulatory residents with cognitive impairments. On 10/04/23 at 10:35 AM, the Director of Nursing stated the storage closets should be latched and locked. A policy titled Safety, Resident reviewed 10/2022 directed staff to ensure all medications, chemicals, cleaning supplies, and any other potential hazardous materials are kept locked/secured when staff has completed their use and is no longer in attendance.

Based on observations, record review, and staff interview, the facility failed to ensure residents who were reliant on enteral nutrition received their tube feeding per physician orders for 2 of 3 residents reviewed for tube feedings (Resident #32 & Resident #63). The facility reported a census of 68 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #32, dated 7/3/23 identified the presence of short and long-term memory impairment. The MDS documented diagnoses that included stroke, seizure disorder, and dysphagia (difficulty swallowing foods or liquid). The MDS recorded the resident received 51% or greater of total calories through tube feeding and 501 cc/day (cubic centimeters per day) or more fluid intake per tube feeding. The Care Plan of Resident #32 revealed a focus area of the resident requiring a feeding tube for nutritional support dated 6/20/22. The Treatment Administration Record revealed an active order for enteral feed of Jevity 1.2 enteral nutrition at 75 milliliters per hour (mls/hr). Observation on 10/2/23 at 4:58 am revealed the feeding pump was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and policy review, the facility failed to provide adequate pain management for 1 of 17 residents reviewed (#7). The facility reported a census of 68 residents. Findings include: On 10/02/23 at 6:25 AM, Resident #7 asked Staff C, Certified Medication Aide (CMA) for pain medication. Staff C told resident #7 he would get it in a little bit. At 6:45 AM, Resident #7 asked another staff member for his pain medication. The staff member told Staff C that the resident requested pain medication. Staff C walked past the resident and told the resident he hadn't forgotten about him and would get his medication in a little bit. At 6:55 AM, Staff C began looking through the medication cart for another resident's medications. Resident #7 asked Staff C whose medications he was looking for. Staff C closed the medication drawer and opened the locked narcotic bin and got Resident #7's pain medication The Electronic Health Record (EHR) included diagnoses of bilateral pes…

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 complete pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis treatment (Resident #17). The facility reported a census of 68 residents. Findings include: On 10/03/23 at 9:49 AM, Resident #17 stated that his vital signs were not always taken at the facility before and/or after dialysis treatment. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had diagnoses of End Stage Renal Disease, Diabetes Mellitus, anemia, and heart failure. The MDS identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. It also revealed the resident received dialysis treatment within the last 14 days. The Electronic Health Record (EHR) indicated the resident's dialysis days were three (3) times per week every Monday, Wednesday, and Friday beginning 9/08/23 at 10:00 AM. The EHR included an order on 9/08/23 to discontinue dialysis center post dialysis…

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 provide a complete, accurate, and detailed record for resident medication administration for 1 of 1 resident reviewed and failed to protect resident information from unauthorized access for 1 of 1 resident reviewed. The facility reported a census of 68 residents. Findings include: 1. On 10/02/23 at 5:08 AM, a stack of skin observation - shower sheets were noted on the nurses' station counter unsecured with a resident's name and skin assessment data listed. On 10/04/23 at 10:35 AM, the Director of Nursing stated resident information documents should be out of sight of anyone who does not need the information; otherwise, it should be flipped over. A policy titled Safeguards for PHI (Personal Health Information) dated 01/2017 indicated PHI will be safeguarded against unauthorized use, access or disclosure in accordance with federal and state laws to prevent access by unauthorized persons. It directed staff to store all documents containing PHI in a secure, locked location with limited access 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, and policy review, the facility failed to provide a call system for resident access for 2 of 19 residents sampled (Resident #9 & #32). Findings include: The Minimum Data Set (MDS) of Resident #9, dated 7/18/23 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The Care Plan of Resident #9 revealed a focus area of Activity of Daily Living (ADL) deficit dated 8/1/23. The Care Plan directed to encourage the resident to use bell to call for assistance. The MDS of Resident #32, dated 7/3/23 identified the presence of short and long-term memory impairment. The Care Plan of Resident #32 revealed a focus area of alteration in musculoskeletal status, dated 10/17/22. The Care Plan directed staff to be sure call light is within reach and respond promptly to all requests for assistance. On 10/2/23 at 4:58 am, Resident #32 was observed sleeping in bed. His call light was observed sitting on the dresser out of reach of the resident. On 10/2/23, Resident #9 was observed sleeping in bed. His call light 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.