Fort Dodge Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to transport 1 of 2 residents reviewed for wound care (Resident #23) to their Wound Center appointment. The facility failed to ensure transportation for Resident #23 to attended their scheduled wound treatment appointment, resulting in a delay in wound care. The facility reported a census of 59 residents.Findings include:Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS included diagnoses of hypertension (high blood pressure), acute respiratory failure (new short-term lung failure), and weakness. The Nursing Progress Note dated 11/21/25 at 11:51 PM documented a full assessment for Resident #23 prior to an emergency room transfer for altered mental status. The note included findings of skin alteration to Resident #23's lower left buttock with red areas to his right buttock. Resident #23's Hospital Records dated 11/28/25 at 10:45…

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 interviews, facility policy review, and review of prior survey history, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program to address and prevent the recurrence of previously cited deficiencies. The facility reported a census of 59 residents. Findings include:Review of the facility's Provider History Report revealed the facility received the same deficiency during the current survey and a complaint survey in November 2025 of the deficiency category free of accident hazards and provision of adequate supervision/assistive devices to prevent accidents (F689).In an interview on 2/9/26 at 3:20 PM, the Administrator stated, QAPI meetings are done monthly with the facility's Medical Director attending at least quarterly. They identified resident falls and the QAPI committee looked at the mechanical lift transfers with the previous incidents with the lift happening a few months before. In an interview on 2/9/26 at 3:20 PM, 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 observation, record review, and staff interview, the facility failed to provide Enhanced Barrier Precautions (EBP) for 1 of 3 resident's reviewed (Resident #7), failed to adhere to appropriate Hand Hygiene (HH) practices for 3 of 3 residents reviewed (Resident #7, #11, and #26), and failed to employ infection control practices with catheter care for 1 of 2 residents reviewed (Resident #26). The facility reported a census of 59 residents.Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident depended on staff for all activities of daily living (ADL's). Diagnoses included traumatic spinal cord injury, aphasia (neurological language disorder affecting a person's ability to speak), and quadriplegia (paralysis of all 4 extremities). Resident #7 had a feeding tube. The Care Plan dated 8/29/22 included Resident #7 required a tube feeding related to 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 record review and staff interview, the facility failed to ensure residents were offered/administered influenza and or pneumonia vaccines for 4 of 5 residents reviewed (Resident #2, #5, #6, and #7). The facility reported a census of 59 residents.Findings include: 1) Based on review of a record printed off by the Director of Nursing (DON) on 2/12/26 at 10:12 a.m. Resident #2 was due for an influenza vaccine on 9/1/26. The resident's clinical record lacked documentation she had been offered the flu vaccine. In an email dated 2/16/26 at 11:18 a.m. the DON It appeared Resident #2 was due for the flu vaccine on 9/1/25. The DON had not found that she received them. Unfortunately, the vaccine provider had not sent a list of vaccines he provided. 2) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #5 was not up to date with the influenza vaccine. The resident's clinical record lacked documentation he had been offered the flu vaccine. 3) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #6 had the flu vaccine 11/8/25, but not up to date on other…

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

Based on record review and staff interview, the facility failed to ensure residents were offered/administered COVID vaccines for 5 of 5 residents reviewed (Resident #2, #5, #6, #7 and #10). The facility reported a census of 59 residents. Findings include:1) Review of an immunization record printed off by the Director of Nursing (DON) on 2/12/26 at 10:12 a.m. indicated Resident #2 was due for a COVID-19 vaccine on 9/1/25. The resident's clinical record lacked documentation she had been offered the COVID-19 vaccine. In an email dated 2/16/26 at 11:18 a.m. the DON It appeared Resident #2 was due for the COVID vaccine on 9/1/25. The DON had not found that she received them. Unfortunately, the vaccine provider had not sent a list of vaccines he provided. 2) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #5 was not up to date with the COVID-19 vaccine. The resident's clinical record lacked documentation he had been offered the COVID vaccine. 3) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #6 was not up to date with vaccines. The resident's clinical…

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, photos, staff interview, and facility policy review the facility failed to maintain resident rooms and care equipment in a clean, sanitary and homelike environment. The reported a census of 64 residents.Findings include:1. On 8/14/25 at 1:38 PM observed dried, brown, long, running stains that ran down the wall beside Resident #4's bed.On 8/15/25 at 1:30 PM witnessed Resident #4's wall continued to have the stains.On 8/27/25 at 11:00 AM witnessed the stains remained on Resident #4's wall. Photos taken during an observation on 8/15/25 at 11:10 AM revealed the following: a. Buildup of dust, dirt, and debris on a stand-up lift device positioned along the wall on the 100 hallway. b. Buildup of a brown/rust substance along a scale device attached to the anterior portion of a total lift device also positioned along the wall on the 100 hallway. Photos taken during an observation on 8/15/25 at 11:30 PM revealed the following: a. A bedside fall mat positioned beside Resident #4's bed contained a torn…

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, Emergency Medical Services (EMS) interview, and review of the facilities Resident Rights, the facility staff failed to treat 1 of 3 residents with dignity and respect during a medical crisis (Resident #2). The facility identified a census of 64 resident. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognitive skills. Resident #2 required substantial to maximum assistance with toileting and hygiene. The MDS listed Resident #2 as non-ambulatory. The MDS listed Resident #2 as always incontinent of urine and frequently incontinent of bowels. The MDS included diagnoses of non-Alzheimer's dementia, other signs and symptoms with cognitive functions and awareness, age-related physical debility, sciatica (pain from pressure on a nerve in the back that goes down a leg), weakness, type ii diabetes mellitus (dm), and end stage renal…

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 facility policy review the facility failed to complete an accurate Minimum Data Set Assessment (MDS) for 1 of 3 residents with multiple skin issues (Resident #4). The facility identified a census of 64 residents. Findings include: Resident #4's MDS assessment dated [DATE], indicated he had a short- and long-term memory deficit and severely impaired cognition. The MDS listed Resident #4 as dependent on staff with activities of daily living (ADL's). The MDS reflected Resident #4 didn't walk. The MDS included diagnoses of type II diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia and malnutrition. The MDS indicated Resident #4 didn't have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The MDS identified he had a risk for pressure ulcers/injuries. The MDS reflected he had diabetic foot ulcer(s). He had pressure reducing devices in the bed and chair, but didn't have a turning/repositioning program.Resident #4's MDS assessment…

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, family interview and facility policy review the facility failed to follow Physician orders for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 64 residents. Findings include:A Progress Record form dated 7/10/25 indicated Resident #1 received a physician's order for a wound vacuum (vac) at 125 mmHg (millimeters of mercury which measured the pressure of the device), to start when available. The order directed to run continuously and changed every Monday, Wednesday and Friday.The Order Details form dated 7/15/25 at 5:52 PM directed to change the wound vac every 30 minutes on Monday, Wednesday and Friday starting 7/16/25.According to a Medication Admin Audit Report form printed 8/26/25 at 1:58 PM identified Resident #1's schedule to change wound vac on 7/16/25 as 6:00 AM, 6:30 AM, and 7:00 AM. The record indicated the nurse did the wound dressing at 5:09 AM, 10:59 AM, and 11:00 AM.The eMAR - Medication Administration Note dated 7/16/25 at 4:52 AM indicated Resident #1 got his wound vac changed twice the day…

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 policy review, resident, and staff interviews the facility failed to ensure they had medications available at the facility to administer as ordered by the physician for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 63 residents. Findings include Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #2 required partial/moderate assistance with their activities of daily living (ADLs). The included diagnoses of hypertension (high blood pressure), diabetes mellitus, depression, and oral cavity (mouth) with obvious or likely cavity or broken natural teeth. The Care Plan Focus initiated 4/3/25 and resolved on 4/30/25 indicated Resident #2 received an antifungal medication due to thrush (a fungus infection of the mouth and throat). The Interventions instructed: a. 4/9/25: Administer antipyretic (medication used to decrease…

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 reviews, staff interviews, hospital staff interviews, and policy review, the facility failed to provide timely intervention to a resident with a change in condition for 1 of 3 residents reviewed (Resident #1) for assessment and intervention. After the return of Resident #1's return to the facility from the hospital, he continued to have elevated blood sugars. The facility staff failed to provide timely intervention for Resident #1's elevated blood sugars that had a poor oral intake, only drinking chocolate milk. On 3/21/25, Resident #1 admitted to the hospital with diabetic ketoacidosis (an imbalance of the body's electrolytes due to an inadequate insulin intake that is a medical emergency). The facility reported a census of 56 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Resident #1 required staff supervision with eating. The MDS 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 clinical record review, staff interviews, and policy review the facility staff failed to notify the physician in a timely manner of changes in a resident's status, failed to ensure the physician collaborated with the facility staff on the care and treatment of a diabetic resident, and failed to ensure the provider / specialist followed up in a timely manner for a resident's care and needs for 1 of 4 residents reviewed diabetes care and treatment and/or had a change in condition (Resident #1). The facility reported a census of 56 residents. Findings: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Resident #1 required staff supervision with eating. The MDS included diagnoses of diabetes, heart failure, renal insufficiency (impaired kidney function), Alzheimer's disease, and malnutrition (inadequate intake of nutrients). Resident #1 received insulin within the lookback period. Resident #1's 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 observation, record review, staff interview, and policy review, the facility failed to provide services that met professional standards regarding medication administration and following physician orders for 1 of 1 resident reviewed (Resident #213). The facility administered medications outside of the scheduled time frame per facility policy. The facility reported a census of 56 residents. Findings include: Resident #213's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #213 required moderate assistance with toileting and extensive assistance with transfers. The MDS listed Resident #213 as occasionally incontinent of bowel and bladder. The MDS included diagnoses of a hip replacement, diabetes, and depression. Resident #213's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the time frame of 11/27/24 through 12/1/24 reflected the following medications given 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 observation, record review, resident and staff interview and policy review the facility failed to ensure call lights were answered within 15 minutes for 3 of 3 residents reviewed (Resident #43 and #213). The facility reported a census of 56 residents. Findings include: 1. Resident #213's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #213 required moderate assistance with toileting and extensive assistance with transfers. The MDS listed Resident #213 as occasionally incontinent of bowel and bladder. The MDS included diagnoses of a hip replacement, diabetes, and depression. The Care Plan initiated 11/21/24 indicated Resident #213 had an actual impairment to their skin integrity due to their right hip surgical wound. The Interventions included to use caution during transfers and bed mobility. The Device Activity Report (Call light log) for the time period of 11/20/24 through 11/27/24 related 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 record review, staff interview and policy review, the facility failed to assure a resident received a physical and occupational therapy evaluation timely upon admission for 1 of 1 resident reviewed (Resident #213). The facility reported a census of 56 residents. Findings include: Resident #213's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #213 required moderate assistance with toileting and extensive assistance with transfers. The MDS listed Resident #213 as occasionally incontinent of bowel and bladder. The MDS included diagnoses of a hip replacement, diabetes, and depression. The Discharge summary dated [DATE], indicated Resident #213 admitted to the hospital on [DATE] for a right total hip arthroplasty due to a diagnosis of osteoarthritis (a condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness) of the right hip. The Summary indicated Resident #213…

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 and procedure review, resident and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 3 residents reviewed, (Resident #1). The facility identified a census of 55 residents. Findings include: 1. The admission Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 4/4/24, documented diagnoses for which included hypertension, diabetes mellitus, anxiety, depression, muscle weakness and cognitive communication deficit. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no cognitive impairment, and able to be understood and has the ability to understand others, and dependent with toileting hygiene and lower body dressing. The Plan of Care with a initiated date 5/4/24, stated the resident was at risk for re-traumatization related to history of trauma due to previous verbal abuse occurring in the past. Interventions include: *Approach in a calm…

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 self report, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents are reported per facility policy to the Iowa Department of Inspection and Appeals within 2 hours, (Resident #1). The facility reported a census of 55 residents. Findings include: 1. The admission Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 4/4/24, documented diagnoses for which included hypertension, diabetes mellitus, anxiety, depression, muscle weakness and cognitive communication deficit. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no cognitive impairment, and able to be understood and has the ability to understand others, and dependent with toileting hygiene and lower body dressing. The Plan of Care with a initiated date 4/9/24, stated the resident has performance deficit related to limited mobility, Musculoskeletal impairment, pain, trauma, and limited…

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 interviews and record review, the facility failed to implement and have an effective pest control program policy. The facility halted routine and as needed visits from their Pest Control provider from 9/1/23 to 1/2/2024. During that time, the facility attempted to treat the facility's bed bug problem with sprays and a heat machine. Findings include: Resident #268's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 2/29/24 at 1:45 PM, Resident #268 reported a nurse told her she had bed bugs. She stated the nurses looked at the bites/rash areas and could tell they were from bed bugs. She stated she didn't know if the facility had the bugs before. She thinks it might have spread but was not positive. She stated she knew the facility treated other resident rooms and bed bugs travel. She reported the facility sprayed her room a couple of times and ran a heater. When they did the heat treatment, they moved her to 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.

F 812 Food Procurement, Store/Prepare/Serve-Sanitary Based on record review and policy review the facility failed to maintain a cleaning schedule for the convection oven. An observation found a dark brown and black substance throughout the convection oven. The facility reported a census of 60 residents. Findings include: During an observation on 2/25/24 at 10:25 AM of the kitchen revealed the convection oven with black substance and crumbs throughout the inside. During an observation on 2/27/24 at 12:34 PM revealed the convection oven continued to have a black substance and debris throughout the inside. The undated and untitled kitchen cleaning schedule provided by the facility lacked instruction on when to clean the convection oven. The Kitchen Sanitation and Cleaning policy revised August 2021 instructed the following: a. Please follow these steps to clean kitchen equipment such as blenders and food processors. i. Turn off and unplug equipment before cleaning ii. Remove food and soil from under and around the equipment iii. Remove any detachable parts iv. Manually wash, rinse, 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 clinical record review, staff interviews and policy review the facility failed to document bed bug assessments, treatments and eradication (removal) for 4 out of 4 residents reviewed (Residents #268, #44, #267, #11). In addition, the facility failed to accurately document bed bug treatments in resident's rooms and provided conflicting information regarding the fire alarm response and temperatures of a room during heat treatment. Findings include: 1. Resident #268's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 2/29/24 at 1:45 PM, Resident #268 reported a nurse told her she had bed bugs. She stated the nurses looked at the bites/rash areas and could tell they were from bed bugs. She stated she didn't know if the facility had the bugs before. She thinks it might have spread but was not positive. She stated she knew the facility treated other resident rooms and bed bugs travel. She reported the facility…

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

Based on personnel file reviews, facility policy review and staff interviews, the facility failed to provide the required 2-hour dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff F). The facility identified a census of 60 residents. Findings include: Staff F, Dietary Aide's, personnel file listed a hired date of 4/28/23. The personnel file lacked a completed dependent adult abuse (DAA) training. On 2/27/24 at 4:20 PM, Staff G, Business Office Manager, reported Staff F completed his DAA training on 2/27/24. Staff G acknowledged Staff F took the Dependent Adult Abuse training. On 2/27/24 at 5:00 PM, the Administrator reported she expected the staff to complete the Dependent Adult Abuse Training within 6 months of hire. The Abuse Prevention and Reporting policy revised May 2007 directed employees receive instruction on what constitutes abuse and reporting requirements during orientation and periodically during ongoing in-service education. The policy failed to address completing a dependent adult abuse training within 6 months of hire and/or…

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 and staff interview the facility failed to ensure a resident had advanced directives (do not resuscitate (DNR) or full code (CPR)) in place for 1 of 16 residents reviewed (Resident #28). The advanced directives provide direction for the staff if the resident is unable to speak for themselves in an emergency, such as their heart stopped beating. Findings include: Resident #28's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of [DATE]. Resident #28's Clinical Physician Orders reviewed on [DATE] listed her code status as a DNR (do not provide chest compressions in case their heart stopped). Resident #28's Medical Record reviewed on [DATE] lacked a signed Advanced Directive by herself and medical provider regarding her wishes, since admission to the facility. During an interview on [DATE] at 10:24 AM the facility's Nurse Consultant reported the facility didn't have an Advance Directive for Resident #28. The Advance Directives policy, revised [DATE], instructed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to notify the Physician when a resident had a change of condition for 1 of 2 residents reviewed (Resident #24) for urinary tract infections (UTIs). Findings include: Resident #24's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #24 as independent with bed mobility, transfers, toilet transfers, and walking 150 feet. The MDS documented reflected Resident #24 had occasional incontinence of urine and didn't have a toileting program. Resident #24's MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), renal disease (kidney), diabetes mellitus, asthma, adjustment disorder with mixed anxiety and depressed mood (short-term disorder that results due to significant changes in the person's life). Resident #24's Laboratory report dated 2/14/24 reflected the staff collected a urinalysis microscopic…

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 interview and record review, the facility failed to provide the bed hold notice policy for 1 of 3 residents reviewed (Resident #267). Findings include: A Progress Note dated 10/26/23 at 12:53 PM, identified while at the facility, the Nurse Practitioner directed to send Resident #267 to the ER (emergency room) for a workup. A Progress Note dated 10/26/23 at 1:30 PM, documented Resident #267 left the facility via ambulance. Resident #267's clinical record lacked a bed hold. On 2/29/24 at 1:23 PM, the Director of Nursing (DON), said she talked with the nurse who sent Resident #267 to the hospital and determined they didn't have a completed bed hold. The DON acknowledged the nurse should have completed a bed hold. An Admission/Discharge/Transfer policy with the subject of Bed Hold dated November 2016, directed staff that the resident, or the resident's representative, shall be informed, in writing, of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or for a therapeutic leave.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interviews and policy review the facility failed to implement 1 of 6 residents (resident #57) activity preferences on her Baseline Care Plan. Findings include: Resident #57's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 11/3/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS included diagnoses of stroke and aphasia (difficulty talking). Resident #57's undated Baseline Care Plan, lacked activities she desires. On 2/28/2024 at 10:30 AM the Nurse Consultant reported she couldn't find Resident #57's activity attendance records. The Baseline Care Plan policy dated May 2021 instructed the facility to develop and implement a Baseline Care Plan within 48's hours of the resident's admission that includes instructions needed to provided effective and person-centered care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, family, and staff interview the facility failed to include a resident's activities preferences on their Care Plan 1 of 6 residents reviewed (Resident #57). Findings include: Resident #57's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 11/3/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS included diagnoses of stroke and aphasia (difficulty talking). During an interview on 2/26/24 at 1:17 PM Resident #57's family revealed Resident #57 used to sing in the church choir and wished they would ask her to attend music. Resident #57's family added she told them, they never ask her to come. Resident #57's Care Plan dated 2/27/24 lacked her activities preferences. On 2/28/2024 at 10:30 AM the Nurse Consultant reported she couldn't find Resident #57's activity attendance records. The Care Planning policy revised September 2020 instructed the facility to develop 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, interviews, and record review, the facility failed to revise a Care Plan for 1 of 20 residents reviewed (Resident #1). Resident #1 received nutrition through a tube feeding (TF). When their primary care provider (PCP) discontinued the order for Pleasure Foods, the facility failed to remove it from Resident #1's plan of care. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The Clinical Physician's Order reviewed on 3/5/24 included the following orders dated: a. 5/3/19: Give Jevity 1 Cal (Nutritional Supplements) Liquid 83 milliliters (ml) per (/) hour (hr.) via gastrostomy (hole into the stomach through the abdomen) tube (G-tube) one time a day. Run from 7 PM to 7 AM. b. 3/23/22: Discontinue the order of pleasure feeding of pureed diet with thin liquid consistency. The Care Plan Focus dated 1/7/18 indicated Resident #1 had an actual nutritional problem…

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, interviews, and record review, the facility failed to discontinue the order provided by the primary care physician for one resident reviewed (Resident #1). Resident #1 received nutrition through a tube feeding (TF). After the PCP gave an order to discontinue Pleasure Foods, the facility continued to give her food and drink by mouth touch to taste without an order. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS included diagnoses of quadriplegia (extreme weakness to paralysis of all four extremities) and traumatic brain injury (TBI). Resident #1 got their nutrition via a feeding tube. The Clinical Physician's Order reviewed on 3/5/24 included the following orders dated: a. 5/3/19: Give Jevity 1 Cal (Nutritional Supplements) Liquid 83 milliliters (ml) per (/) hour (hr.) via gastrostomy (hole into the stomach through the abdomen) tube (G-tube) one…

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, facility policy review, family and staff interview the facility failed to provide documentation of the group, individual, and independent activities provided for 1 of 1 resident reviewed (Resident #57) for activities. In addition, the facility failed to provide Resident #57 with activities that met her interests and supported her physical, mental, and psychosocial well-being. Findings include: Resident #57's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 11/3/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS included diagnoses of stroke and aphasia (difficulty talking). On 2/28/2024 at 10:30 AM the Nurse Consultant reported she couldn't find Resident #57's activity attendance records. The Activities Supervisor job description labeled Activities Director (AD) dated 12/27/21, directed the AD to plan, organize, develop, and direct the overall operation of the Activities Department in…

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, staff interview, facility records and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility for 1 of 5 residents reviewed (Resident #48). Findings include: Resident #48's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 2/26/24 at 1:31 PM, Resident #48 reported the facility had low staffing on the weekends. She could tell because she didn't see anyone. The call light times are worse on the weekend when they are short staffed. Her call light can be on for 30 minutes up to an hour. She stated her hip is bone on bone and it is too hard for her to sit that long on the toilet. Her roommate has gone to find someone to get her off the toilet. She stated she times the call light with a clock. She stated she is not bashful and has told staff and management about her concerns with the call light. 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 observation, clinical record review, facility policy review, staff, and resident interviews the facility failed to assess and provide interventions necessary for the care and services to maintain the resident's highest practical physical well-being for 3 of 5 residents reviewed with skin impairments, and failed to complete timely resident assessments on admission and re-admission for 3 of 5 residents who required wound care and/or such assessments. (Resident #1, #3 and #7). Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS reflected that Resident #1 did not have behaviors and did not resist cares. The assessment indicated that he needed limited assistance from two persons for bed mobility, and extensive assistance from two persons for transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses of coronary artery disease (narrowing of 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, facility policy, and staff interview, the facility failed to provide care consistent with professional standards of practice, to provide necessary treatment and services to promote the healing of a pressure ulcer, for 1 of 4 residents reviewed (Resident #5). Due to the inadequate care Resident #5's pressure ulcer declined and got larger. Findings include: The MDS 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 only, 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 bone, tendon or muscle is 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.