Salem Lutheran Home

Based on document review, staff interviews, and the facility policy review, the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment for 1 out of 5 staff reviewed. The facility reported a census of 49 residents. Findings include: A review of personnel file of Staff G, Licensed Practical Nurse (LPN), revealed the background check was completed 3/15/25 while the hired date was 10/8/24. Background check was not completed prior to hire date. In an interview with Staff H, Human Resources, on 06/24/25 02:29 pm, she stated during an internal audit they didn't locate a background check on Staff G, LPN and they completed one immediately on 3/15/25. During an interview with the DON on 6/24/25 at 2:35 pm, she confirmed that the facility failed to complete a required background check prior to hiring Staff G. Review of the facility provided policy titled Abuse and Neglect-Rehab/Skilled, Adult Day Services, Therapy & Rehab revised 4/7/2025 documented: The location will not knowingly employ or otherwise engage individuals who have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record review, resident interview, personnel file review, facility policy review, and staff interview the facility failed to investigate and report alleged violations related to mistreatment to officials including the State Survey Agency in an appropriate time frame for 1 of 1 residents (Resident #37). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS reflected Resident #37 diagnoses of cerebrovascular accident (CVA), transient ischemic attack (TIA) or stroke, hemiplegia or hemiparesis, and diabetes mellitus. The MDS further documented Resident #37 required total dependence of staff for performing toilet transfers and toileting hygiene. During interview on 6/24/25 at 11:16 am Resident #37 stated Staff F, Certified Nursing Assistant (CNA) was providing cares to her before bed time on 2/5/25 and left her 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 and staff interview, the facility failed to refer 2 residents with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who were later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 2 residents reviewed for PASRR requirements (Resident #16, #20). The facility reported a census of 49 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #16 documented a Brief Interview for Mental Status (BIMS) did not indicate a summary score. The MDS documented an admission date of 6/14/23. The MDS documented high-risk drug classes use and indicated Resident #16 was taking antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. The Electronic Health Record (EHR) documented Resident #16 had the following diagnoses: psychological insomnia,…

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, resident and staff interviews, the facility failed to provide quality of nursing care by leaving a resident on a bed pan for an extensive period of time without a call light and not documenting the event for 1 of 1 residents reviewed (Resident #37). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS reflected Resident #37 diagnosis of cerebrovascular accident (CVA), transient ischemic attack (TIA) or stroke, hemiplegia or hemiparesis, and diabetes mellitus. The MDS further documented Resident #37 required total dependence on staff for performing toilet transfers and toileting hygiene. During an interview on 6/24/25 at 11:16 am Resident #37 stated Staff F, Certified Nursing Assistant (CNA) was providing toileting hygiene on 2/5/25 and left her on the bed pan for 5 hours without a call light within reach.…

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. Review of Resident #8's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The MDS further revealed Resident #8 utilizes oxygen therapy. Review of Resident #8's EHR page titled, Physician's orders revealed an order for oxygen 1 Liters Per Minute (LPM) per nasal cannula at night while sleeping. Interview 6/23/25 at 1:02 PM with Resident #8 revealed that she just puts the oxygen on, and is unsure how often the tubing is changed. Observation 6/23/25 at 1:02 PM oxygen tubing was noted to be dated 4/16/25, and humidification bottle was noted to be dated 4/23/25. Interview 6/24/25 at 10:37 AM with Staff A RN (Registered Nurse) revealed she works here every other weekend with an agency, and oxygen tubing is to be changed weekly on Wednesdays. Staff A then revealed that there is a book that shows oxygen tubing is to be changed weekly on Wednesday nights. Review of an undated facility provided document titled, Master Schedule 6p-6a Center Nurse, revealed Wednesdays oxygen tubing and nebulizer…

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. Review of Resident #9's MDS dated [DATE] revealed an admission date to the facility from a short-term general hospital stay 5/13/24. The MDS further revealed Resident #9 utilizes an indwelling catheter. Review of Resident #9's EHR page titled, Clinical Physician ' s Orders revealed an order for coudé (a type of urinary catheter with a curved or bent tip) catheter for infection control with a date of 4/22/25. Observation 6/25/25 at 11:06 AM Staff D Certified Nursing Assistant (CNA) brought Resident #9 into the bedroom to empty Resident #9's catheter drainage bag. Staff D then donned a gown and gloves with no hand hygiene. Staff D then obtained a urine graduate and placed it on a barrier on the floor. Staff D then drained the drainage bag without cleaning the drainage port of the drainage bag. After the drainage bag was emptied Staff D cleansed the drainage port with an alcohol wipe. Staff D then emptied the graduate. Staff D donned the gloves and gown with no hand hygiene and left the room. Interview 6/25/25…

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, facility investigative file, staff interviews, resident interviews and facility policy review the facility failed to ensure staff followed professional standards while administering medications for 4 of 4 residents reviewed (Resident #3, #4, #5, and #6). The facility reported a census of 45 residents. Findings include: 1. According to the significant change Minimum Data Set (MDS) assessment tool with a reference date of 9/16/24 Resident #3 had a Brief Interview of Mental Status (MDS) score of 14. A BIMS score of 14 suggested no cognitive impairment. On 10/16/24 at 11:30 AM Resident #3 was sitting in her recliner in her room listening to an audiobook with her oxygen on via nasal cannula from an oxygen concentrator. When asked if she felt her medications were being given as ordered she stated oh gosh yes, at least she thought. She added she has to be careful because she takes a lot of pills because of her heart failure. She had recent been to the hospital because she was short of breath and found to have a lot of fluid around her heart. She is feeling much…

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, record review, facility camera footage review, staff interviews, resident interviews and facility policy review the facility failed to ensure 1 of 3 residents (Resident #1) was free from financial exploitation. The facility reported a census of 45 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 7/30/24 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 documented the following diagnoses for Resident #1: atrial fibrillation, diabetes mellitus, depression, spinal stenosis, pulmonary hypertension, sleep apnea, proteinuria, long term use of insulin, and morbid obesity. The Care Plan had the following focus areas: Resident #1 was on diabetic therapy (initiated 7/11/24), the resident has diabetes mellitus (initiated 7/11/24), and had a potential nutritional problem related to the diagnoses of morbid obesity, type 2 diabetes mellitus, depression, and GERD (initiated 7/26/24). On 10/15/24 at 3:19 PM…

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

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to prevent cross-contamination while serving food. The facility reported a census of 49 residents. Findings include: On 8/10/24 at 11:45 AM a continuous observation revealed, Staff I used tongs to move plastic wrap from pan with rolls then grabbed a roll with the same tongs and placed it on a resident's plate. She also used the same tongs to remove aluminum foil from a casserole pan. Staff I placed butter packets on residents' plates which directly touched the residents' food throughout meal service. At 12:04 PM, Staff I placed her right hand on the steam table counter and waited for a staff member to take the prepared plate from her left hand. She grabbed dedicated food scissors and cut a resident's meat into bite sized portions, placed the scissors on the steam table counter where her hand had been, picked up the scissors and cut two (2) more residents' meat into bite sized portions. At 12:10 PM, Staff I moved 2 pans from the left side of the steam table area and…

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

Based on observations, menu review, and staff interviews, the facility failed to properly prepare and serve the appropriate portions of pureed diets for 3 of 3 residents and minced and moist diets for 7 of 7 residents. The facility reported a census of 49. Findings include: The facility's lunch menu for 8/10/24 identified the following items to be served as part of the following planned textured diets. A) Pureed diet: 5 fluid ounces (fl oz) of ground/minced baked pork chop 4 fl oz of mashed potatoes 4 fl oz of pureed carrots (substitution for buttered summer squash) 1 each pureed bread slice 3 fl oz pureed peaches 8 fluid oz 2% milk 6 fl oz black coffee or tea B) Minced & Moist diet: 4 fluid ounces (fl oz) of pureed baked pork chop 4 fl oz of mashed potatoes 4 fl oz of pureed carrots (substitution for buttered summer squash) 1 each pureed bread slice 4 fl oz pureed peaches 8 fluid oz 2% milk 6 fl oz black coffee or tea Continuous observation of lunch preparation and service began on 8/10/24 at 10:20 AM. Staff I, Cook, stated she was preparing minced & moist diets for 9 servings. She…

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. The facility reported a census of 49 residents. Findings include: On 8/09/24 at 3:45 PM, an observation revealed an open laptop screen with visible resident Electronic Health Record (EHR) information. A sheet was face-up on the cart with resident names, room numbers, blood glucose results, and insulin. At 3:47 PM, Staff D, Certified Nurse Aide, (CNA) stated staff usually did not leave the information visible and the screen is usually locked. At 3:50 PM, Staff F, Registered Nurse (RN) stated she used the sheet as her cheat sheet so she would not forget the information. A policy titled Confidentiality revised 5/06/24 indicated individuals who have access to confidential information must ensure that such info4matinon, in whatever form it exists, is handled strictly in accordance with the policy and applicable legal, accreditation and regulatory requirements regarding safeguarding confidential information. On 8/11/24 at 2:08 PM, the…

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

Based on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during toileting and urinary catheter care for 2 of 2 residents (Resident #1, Resident #35) observed. The facility also failed to perform hand hygiene between feeding two (2) residents. The facility reported a total census of 49 residents. Findings include: 1. Observation on 08/10/24 at 2:08 PM, Staff A, Certified Nursing Assistant (CNA) donned personal protective equipment (PPE) then assisted Resident #10 to the bathroom. Staff A lowered the resident's pants and incontinence brief then assisted the resident to sit on the toilet. Staff A removed and discarded soiled gloves, reached beneath her PPE gown, and retrieved hand sanitizer. Staff A performed hand hygiene then donned new gloves. After Resident #10 attempted to have a bowel movement, Staff A cleansed Resident # 10's buttock, pulled up his incontinence brief and pants, then sat the resident back on the toilet. Staff A removed and discarded soiled gloves. Staff A failed to perform hand hygiene, then donned new gloves.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview and facility policy review, the facility failed to complete a bed hold notice with the resident or resident's responsible person when residents transferred out of the facility for 1 of 2 residents reviewed (Residents #12). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented a discharge from the facility with return anticipated. Review of Resident #12's Progress Notes revealed the following information: a. On 7/14/24 Resident #12 admitted to the hospital. b. On 7/16/24 Resident #12 returned to the facility at 3:00 PM. Review of the Resident #12's census tab revealed the following information: a. 7/14/24 hospital start date b. 7/16/24 hospital end date The MDS assessment dated [DATE] for Resident #12 documented a reentry into the facility on 7/16/24. Review of Resident #12's clinical record revealed the facility lacked a bed hold notice for the hospital admission 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, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 2 residents (Resident #20), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 49 residents. Findings include: Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficit. The MDS further revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of a facility provided document titled, The Preadmission Screening and Resident Review (PASRR) Level I Screen Outcome, dated 10/28/21 revealed a summary of findings indicating that Resident #20 did not show evidence of a serious mental illness or an intellectual or developmental disability (IDD) that appears to require PASRR intervention. The document provided the resident had a diagnosis of major depressive…

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

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to develop a resident-centered comprehensive care plan for 3 of 3 residents reviewed (Resident #5, #18, and #39). The facility reported a census of 49 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 7/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of cancer, Non-Alzheimer's dementia, seizure disorder, anxiety, depression, and insomnia. It also revealed the resident was independent with eating, required setup assistance with oral hygiene, and moderate to maximum assistance with all other Activities of Daily Living (ADLs). It further indicated the resident took antipsychotic and antidepressant medications within the last 7 days. The Clinical Physician Orders dated 8/10/24 included the following prescribed medications: a) Prozac Capsule 20 MG (FLUoxetine HCl) Give 20 mg by mouth in the morning related to major depressive disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, policy review and staff interview the facility failed to revise and update a care plan to include current transfer needs for 3 out of 4 residents reviewed (Resident #24, Resident #42, and Resident #16). The facility reported a census of 49 residents. Findings Included: 1. The Minimum Data Set (MDS) assessment dated 611/24 for Resident #24 documented diagnoses of pain in the left knee, muscle weakness and heart failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The Progress Notes for Resident #24 showed the following: a. On 8/6/24 at 3:08 PM Resident #24 returned back to the facility after a procedure. Resident #24 reported having pain down her left leg. b. On 8/7/24 at 6:47 PM Resident #24 required a total lift to transfer to the wheelchair. In an interview on 8/9/24 at 1:46 PM, Resident #24 reported she received a Kyphoplasty procedure due to a compression fracture. Resident #4 reported she…

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

Based on observations, clinical record review, and policy review the facility failed to ensure physician's orders were followed for 1 of 1 resident (Resident #46) reviewed. The facility identified a census of 49 residents. Findings include: On 8/09/24 at 1:22 PM, an observation revealed Resident #46's oxygen flow meter was set to 4 liters per minute (LPM). The resident stated he required oxygen continuously. The admission Minimum Data Set (MDS) assessment for Resident #46 dated 7/02/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Atrial Fibrillation (irregular heart beat), Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and deep venous thrombosis (DVT - blood clot in deep veins). It revealed the resident was independent with eating and oral hygiene but required moderate to maximum assistance with all other Activities of Daily Living (ADLs) and received oxygen therapy upon admission and in the 14-day look-back period. 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 observation, clinical record review, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic mediation use for 2 of 3 residents reviewed ( Resident #18 & #39). The facility reported a census of 49 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment for Resident #18 dated 7/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 which indicated severely impaired cognition. It included diagnoses of anxiety, depression, concussion with loss of consciousness, cerebral infarction (stroke caused by blocked blood vessel to the brain), schizotypal disorder (personality disorder causing eccentric behavior and anxiety with close relationships), and metabolic encephalopathy (brain dysfunction caused by chemical imbalances in the blood). It revealed the resident required setup assistance with oral hygiene, supervision with eating, and was dependent with all other Activities of Daily Living (ADLs). It further indicated the resident took antipsychotic, antidepressant, antianxiety, 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 observations, electronic health record (EHR) review, document review, resident interviews, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 2 of 5 resident reviewed (Resident #9 and #10). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #9 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS indicated Resident #9 as frequently incontinent of urine and occasionally incontinent of bowel. On 5/14/24 at 1:52 PM Resident #9 stated she used her call light all the time and it was the only way she could get help. Resident #9 stated the staff frequently took longer than 15 minutes to respond to her call light. Resident #9 stated the staff needed more help. Resident #9 stated she turned the call light on that morning because she wanted to get out of bed. Resident #9 stated she waited 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 observations, clinical record review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when completing blood sugar monitoring for 3 of 3 residents reviewed (Resident #4, #5, and #6). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating moderate cognitive impairment. The MDS documented Resident #4 had a diagnosis of type 2 diabetes Mellitus. Review of Resident #4's Clinical Physician Orders documented an order dated 10/10/23 for blood glucose monitoring 4 times a day. On 5/14/24 at 11:30 AM observed Resident #4 being pushed down the hall by Staff C into an unoccupied room. Staff C returned to the medication cart to retrieve the blood glucose machine and supplies. Staff C applied gloves without completing hand hygiene. Staff C entered the room and cleansed Resident #4's right hand index finger with…

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 review of the facility schedule and staff interviews, the facility failed to have a Registered Nurse (RN) on duty for 8 hours a day, 7 days per week. The facility reported a census of 49 residents. Findings included: The review of the facility's April 2023 nursing staff schedule lacked a RN on duty for 8 hours on the following days: a. 4/29/23 b. 4/30/23 The review of the facility's May 2023 nursing staff schedule lacked a RN on duty for 8 hours on the following days: a. 5/6/23 b. 5/20/23 c. 5/27/23 d. 5/28/23 On 6/1/23 at 6:45 AM, Staff C, Licensed Practical Nurse (LPN), reported the facility did not have eight hours of RN coverage on the weekends. On 6/1/23 at 12:14 PM, the Director of Nursing (DON), confirmed that the facility lacked RN coverage on the dates listed. The DON acknowledged that she expected the facility to have 8 hours of RN coverage every day. The facility failed to provide a policy related to RN staffing requirements.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record review the facility failed to destroy and have an accurate account for discontinued narcotic medications for 2 of 2 residents reviewed (Residents #25 and #101). Resident #25 and Resident #101 had their narcotic medications discontinued but the pills remained in the medication storage room and the medication cart. Findings include: 1. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #25 required total dependence for transfers with help of 2 persons. The MDS indicated that Resident #25 received no opioids in the previous seven days of the lookback period. The Care Plan Focus revised 6/23/22 indicated that Resident #25 had chronic pain and discomfort related to a history of a fractured ankle and arthritis as evidenced by (AEB) her experiencing pain at times. The Interventions directed a Black Box Warning related to Tramadol due to a risk of medication…

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, resident, and staff interviews the facility failed to serve hot food to residents in their rooms. The facility reported a census of 48 residents. Findings include: On 5/31/23 at 11:34 AM observed the [NAME] check the temperature of the food on steam table within appropriate temperatures. After serving the dining room residents, the [NAME] prepared the room trays. On 5/31/23 at 12:43 PM observed 10 resident room trays and an extra tray placed in an enclosed food carrier. Someone immediately paged to notify the staff that South room trays were ready. On 5/31/23 at 12:46 PM witnessed three room trays ready for the [NAME] Hall. The staff paged that the [NAME] Hall trays were ready. Staff A, Certified Nursing Assistant (CNA), retrieved the [NAME] food cart and deliver the three trays. On 5/31/23 at 1:00 PM watched Staff A take the South cart from the kitchen. Staff A served the final room tray at 1:15 PM. Observed Staff A take the temperature of the extra tray. The temperature measured 111 degrees Fahrenheit. On 6/1/23 at 11:55 AM the Director of Nursing (DON)…

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 ensure resident's current code status was available for 1 out of 16 residents reviewed (Resident #201). Findings include: Resident #201's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of [DATE] from an acute hospital. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS included diagnoses of renal disease, depression, arthritis, and right side back pain with sciatica. Review of the facility's Code Status Binder revealed a form titled Iowa Physician Orders Scope of Treatment (IPOST). The IPOST indicated that Resident #201 chose to have a Do Not Attempt to Resuscitate (DNR) status with comfort measures only. The IPOST documented comfort measures included the use of medications by any route, positioning, wound care, with other measures to relieve pain and suffering. Use of oxygen, suction, and manual treatment of airway obstruction as needed…

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 notify the family for a significant change in condition for 1 of 16 residents reviewed (Residents #42) for pressure ulcers. Findings include: Resident #42's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 14, indicating intact cognition. The MDS indicated that Resident #42 required extensive assistance of two persons with bed mobility and toilet use. The MDS listed that Resident #42 required total dependence of two persons with transfers and could not ambulate. The MDS identified that Resident #42 had an indwelling catheter. The MDS identified Resident #42 is at risk for developing pressure ulcer and that he had an unhealed stage 2 pressure ulcer during the seven-day lookback period. The MDS included diagnoses of hypertension (high blood pressure), obstructive uropathy, end stage renal disease, and malnutrition. The Communication - Other note on 5/3/23 at 10:27…

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 chart review the facility failed to prevent the mishandling of a resident's narcotic medications for 1 of 4 residents reviewed (Resident #38). Findings include: Resident #38's Minimum Data Set (MDS) assessment dated [DATE] listed a re-admission date of 4/19/23 from another nursing home or swing bed. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognitive ability. The MDS listed that Resident #38 activities of daily living (ADL) only occurred once or twice in the lookback period. The Care Plan Focus revised 4/28/23 indicated that Resident #38 had an ADL self-care performance deficit related To hypertension (high blood pressure), a recent fall with a right hip fracture and repair, evidenced by the need for assistance with ADLs On 5/30/23 at 10:30 AM observed Resident #36 dressed and sitting in her recliner in her room. She said that she did not have any pain or concerns about her care. The Incident Note dated 4/12/23 at 7:59 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate the sudden increase of pain for a resident who received scheduled pain medication for chronic pain who used a standing lift for transfers for one of one resident reveiwed (Resident #25). Despite reports that Resident #25 had difficulty standing with the standing mechanical lift, the facility did not investigate the concern. Without investigation of the concern, the staff continued to transfer Resident #25 with the standing mechanical lift. After a change in condition, the facility sent Resident #25 to the hospital who discovered a compression fracture. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, dressing, and toilet use. In addition, she required total dependence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility record review, facility policy review, resident, and staff interviews the facility failed to revise and update the Care Plan to address the increased needs of Activities of Daily Living (ADLs) for 1 of 1 residents reviewed (Resident #25). Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, dressing, and toilet use. In addition, she required total dependence on two persons for transfers, and extensive assistance of one person for personal hygiene. The assessment indicated that Resident #25 could not ambulate (walk) and needed one person to push her wheelchair. The MDS included diagnoses of cancer, heart failure, diabetes, depression, and a compression fracture of the spine (broken bone caused by weakness in the back). On 5/30/23 at 10:53 AM Resident #25 stated she fell out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 16 residents reviewed (Residents #45 and #33). The facility failed to obtain weights as ordered by the physician for Resident #45. In addition, the facility failed to document the administration of medications, blood sugars, and bed time (HS) snacks for a diabetic resident. Findings include: 1. Resident #45's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 13, indicating intact cognition. The MDS included diagnoses of prostate cancer, coronary artery disease, hypertension (high blood pressure), and malnutrition. The Order Details dated 4/4/23 directed to weigh Resident #45 three times a week and report a weight loss or gain of three to five pounds. Resident #45's April 2023 Treatment Administration Record (TAR) included an order dated 4/5/23 to weight him three times per…

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, facility record review, and policy review the facility failed to ensure residents received the necessary interventions and care consistent with professional standards of practice to prevent deterioration of a wound, heal a stage 2 pressure ulcer, and prevent the development of new ulcers for 2 of 2 residents reviewed (Residents #251 and #24). The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but has no bone, tendon…

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 dialysis assessments before and after outpatient hemodialysis treatments for 1 of 1 resident reviewed (Resident #42). Finding include: Resident #42's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 14, indicating intact cognition. The MDS indicated that Resident #42 required extensive assistance of two persons with bed mobility and toilet use. The MDS listed that Resident #42 required total dependence of two persons with transfers and could not ambulate. The MDS identified that Resident #42 had an indwelling catheter. The MDS included diagnoses of hypertension (high blood pressure), obstructive uropathy, end stage renal disease, and malnutrition. Resident #42 received dialysis while a resident of the facility in the last 14 days in the lookback period. The Care Plan Focus revised 5/17/23 identified Resident #42 needed hemodialysis (the process of running…

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 have a complete and accurate medical record for 2 of 16 residents reviewed (Residents #45 and #251). After Resident #45 fell, their clinical record lacked a progress note related to the incident. During incontinence cares, the facility staff observed open areas to Resident #251. After reporting the concerns to the nurse, the clinical record lacked documentation of his open areas. Findings include: Resident #45's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 13, indicating intact cognition. Resident #45 required limited assistance of one person with bed mobility, transfers, and ambulation in his room. The MDS indicated that he required extensive assistance of one person with toilet use. The MDS included diagnoses of prostate cancer, coronary artery disease, hypertension (high blood pressure), and malnutrition. The Incident Report dated 4/21/23 at 2:00 p.m. listed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow hand hygiene and gloving practices consistent with accepted standards of practice for 1 of 2 residents reviewed (Resident #45) while providing catheter care. Findings include: Resident #45's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 13, indicating intact cognition. Resident #45 required limited assistance of one person with bed mobility, transfers, and ambulation in his room. The MDS indicated that he required extensive assistance of one person with toilet use. The MDS listed that Resident #45 had an indwelling catheter. The MDS included diagnoses of prostate cancer, obstructive uropathy (obstructed urinary flow), and a urinary tract infection (UTI) in the last 30 days. The Care Plan…

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.