Good Samaritan - Indianola

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on direct observation, clinical record review, staff interview, resident interview, and facility policy review, the facility failed to maintain appropriate staffing levels to ensure call lights were answered in a timely manner. The facility reported a census of 82. Findings include: A direct observation on 01/13/2026-01/14/2026 during the overnight shift it was observed that three Certified Nurse Aides (CNA) and two Nurses were in the building until Staff B, CNA arrived, increasing the number of certified nurse aides to 4. The building has 4 halls, with the rehab care hall being largely isolated from the building by distance and doors. 1 staff member was observed to be assigned to the rehabilitation hall. In an interview on 01/12/2026 at 01:04 PM with Resident #2, whose brief interview for mental status (BIMS) score was reported in the Assessment Scoring Report as 15, indicating intact cognition, he stated he could not get to the bathroom on his own, and while the staffing levels during the day are often…

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

Based on clinical record review, staff interview, and State Agency Website, the facility failed to make a good faith effort to correct deficient practices resulting in repeated sufficient staffing violations over a three-year period. The facility reported a census of 82. Findings include:Review of the state agency's public website https://dia-hfd.iowa.gov/ contained the following certification actions during the following surveys:Ending on 07/29/2025 resulted in a deficiency cited related to staffing. Ending on 04/24/2025 resulted in a deficiency cited related to staffing. Ending on 01/30/2025 resulted in a deficiency cited related to staffing. Ending on 06/18/2025 resulted in a deficiency cited related to staffing. Review of the Quality Assurance and Performance Improvement Meeting notes dated 12/15/2025 identified assuring appropriate staffing as an active area of the QAPI action plan. In an interview on 01/14/2026 at 03:18 PM with the Administrator, stated the facility had been aware of the need for more staff since before he took over as Administrator in November. He…

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

Based on observation, resident and staff interview, and policy review, the facility failed to respond to resident call lights within 15 minutes for 3 of 6 residents reviewed (#7, #8, #9). The facility also failed to document 15-minute resident checks for Resident #12. The facility reported a census of 88 residents. Findings include: On 7/26/25 at 8:20 PM, State Surveyors entered the facility and observed activated resident call lights (#1, #4, #7, and #8). At 8:23 PM, the State Surveyor was near the nurse's station but without a direct line-of-sight. Staff was overheard having personal conversations while visiting amongst themselves. At 8:25 PM, Resident #9's call light was activated. At 8:26 PM, two (2) staff members passed Residents #1, #4, and #7's rooms and left the unit. At 8:29 PM, a staff member turned off Resident #13's call light and entered Resident #11's room with a mechanical lift. At 8:32 PM, the resident call light notification device at the nurses' station revealed Resident #7's call light had been activated for 20 minutes. At 8:42 PM, a staff member was observed…

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, resident and staff interview, and policy review, the facility failed to speak to the resident in a manner that maintained dignity, failed to change a resident's stained shirt after putting the resident in bed (#4), and delayed feeding a dependent resident (#3). The facility reported a census of 88 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 6/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of cerebrovascular accident (stroke), hemiplegia (one-sided weakness), and chronic obstructive pulmonary disease (COPD). It also indicated the resident required setup assistance for eating and oral hygiene, maximal assistance with upper and lower body dressing and personal hygiene, and was dependent with all other aspects of Activities of Daily Living (ADLs) and mobility. The undated Care Plan revealed the resident had an ADL self-care performance deficit related to a stroke and indicated she required one (1) person…

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 secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 88 residents.Findings included: On 7/29/25 at 9:44 AM, Staff D, Certified Medication Aide (CMA) was observed administering resident's medications. She locked the medication cart and walked into the resident's room. An opaque medication cup was observed on the medication cart with an orange, round pill. A resident who self-propelled in his wheel-chair was observed 3 doors away.At 9:46 AM, Staff D returned to the medication cart, poured water into a cup and returned to the resident's room. The orange, round pill was observed still in the opaque medication cup on the medication cart.At 9:47 AM, Staff D returned to the medication cart. She stated the facility's medication handling and storage process was narcotics were locked in the lock box in the medication cart and all other medications were to be secured in the medication cart and not left accessible when staff leaves the cart unattended. At…

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

Based on observations, staff interview, and policy review the facility failed to implement the infection control policy as staff failed to disinfect a mechanical lift between two residents' use (#4, #11). The facility reported a census of 88 residents.Findings include:On 7/29/25 at 9:16 AM, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA transferred Resident #4 from her wheelchair to her bed. Staff A brought the mechanical lift out of Resident #4's room and placed it against the wall outside, beside Resident #4's door. The mechanical lift was not disinfected. At 9:41 AM, Staff B, CNA and Staff C, CNA took the mechanical lift into Resident #11's room to get Resident #11 out of bed. The mechanical lift was not disinfected prior to use. At 9:49 AM, Staff B, CNA brought the mechanical lift out of Resident #11's room and placed it against the wall between rooms 212 & 214. It was not disinfected. At 9:51 AM, Staff D, Certified Medication Aide (CMA) and Resident #11 stated there was no disinfectants (Saniwipes) kept in the resident's room. Staff D also stated disinfectants were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to ensure staff had access to an accurate code status for 1 of 24 residents reviewed for advance directives (Resident #16). The facility reported a census of 81 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated [DATE], listed diagnoses for Resident #16 which included mild intellectual disabilities, heart failure, and depression. The MDS listed a Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. The facility policy Advance Directives including Cardiopulmonary Resuscitation(CPR) and Automated External Defibrillator(AED), revised [DATE], stated the facility would keep advance directive orders in a binder easily accessible to the nursing staff. On [DATE] at 11:42 a.m., Staff A Registered Nurse(RN) stated he would look in the computer first for code statuses and then would look in the binder at the nursing station next. On [DATE] at 11:42…

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, policy review, and staff interview, the facility failed to ensure floors were clean and non-sticky for 1 of 24 resident rooms reviewed (Resident #16). The facility reported a census of 81 residents. Findings include: The facility policy Housekeeping, Resource Packet, revised 10/2/24, stated the facility would keep a daily schedule for cleaning floors that included more thorough cleaning on a routine schedule. On 4/22/25 at 9:15 a.m., the floor of Resident #16's bathroom was very sticky throughout. While walking, shoes noticeably stuck to the floor. Subsequent observations on 4/23/25 at approximately 8:15 a.m. and 4/24/25 at 9:48 a.m., revealed the floor remained sticky. On 4/24/25 at 1:02 p.m., the Ancillary Services Manager stated he was informed of Resident #16's bathroom floor stickiness today and contacted the floor cleaner company to make sure the cleaning solution dilution ratio was correct. On 4/24/25 at 3:01 p.m., the Administrator stated she had a conversation with the Ancillary Services Manager last week about the solution being too concentrated. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and policy review, the facility failed to update and revise the Care Plan to reflect a resident-to-resident incident and interventions for one of two sampled residents in order to maintain a resident's mental and psychosocial well-being (Resident # 69). The facility reported a census of 81 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had diagnoses of cerebrovascular accident (stroke), hemiplegia, and muscle weakness. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated impaired cognition. The MDS recorded the resident had little interest or pleasure in doing things and felt down and depressed 12-14 days during the look-back period. The resident had impaired range of motion on one side of her body, required partial to moderate assistance for bed mobility, and had dependence on staff for lower body dressing and transfers. The Care Plan revised…

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, policy review, and staff interview, the facility failed to ensure a resident received assistance with incontinence care and nail care for 1 of 4 residents reviewed for activities of daily living(Resident #16). The facility reported a census of 81 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 2/12/25, listed diagnoses for Resident #16 which included mild intellectual disabilities, heart failure, depression. The MDS stated the resident required partial to moderate assistance with toileting hygiene and listed a Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. Care Plan entries, dated 1/15/24, stated the resident used adult disposable briefs and directed staff to check the resident approximately every two hours and assist with toileting as needed. The facility policy Incontinence Care, revised 5/20/24, stated the facility would identify the proper care for residents who needed assistance managing their incontinence and stated all residents…

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

Based on observation, record review, resident and staff interviews, and policy review the facility failed to answer resident call lights in a timely manner, within 15 minutes for one of two nursing units (Lilac/Daisy). The facility staff also failed to address one of four residents needs for incontinence care (Resident # 16). The facility reported a census of 81 residents. Findings include: 1. Observations revealed the following: On 4/22/25 at 11:35 AM, the light above a resident's door in the 100 hall observed to be on. The resident reported her call light had been on for at least 10 minutes. The resident had a clock on the wall in her room to know what time it was and how long it took staff to answer the call light. The resident reported she wanted staff to get her up. At 11:44 AM Staff C, Certified Nursing Assistant (CNA) entered the resident's room. Staff C turned the call light off and told the resident she would be back. At 11:46 AM, the resident pushed her call light again. The resident stated staff always shut her call light off and told her they would be back. This action…

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, policy review, and staff interview, the facility failed to carry out adequate infection control practices to prevent the spread of infection for 1 of 4 residents reviewed for incontinence cares(Resident #16) and failed to carry out enhanced barrier precautions(EPB) for 1 of 4 residents who required EPB. The facility reported a census of 81 residents. Findings included: 1. The Minimum Data Set(MDS) assessment tool, dated 2/12/25, listed diagnoses for Resident #16 which included mild intellectual disabilities, heart failure, depression. The MDS stated the resident required partial to moderate assistance with toileting hygiene and listed a Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. The facility policy Laundry, Resource Packet, revised 8/30/24, stated staff would collect soiled laundry to prevent the spread of potential infectious disease and would treat all soiled clothes and linens soiled with bodily…

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

Based on resident interview, staff interview, and facility document review, the facility failed to provide sufficient staff to provide needed care. The facility reported a census of 78. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #13, dated 12/14/2024, which documented her Brief Interview for Mental Status (BIMS) score as 15, which indicated intact cognition. An interview on 01/28/2025 at 08:15 PM with Resident #13 reporte she doesn't feel the facility had enough staff to provide care for all residents in a timely manner. She noted that she is ambulatory, and can transfer herself, but that her roommate can't and she has had to resort to leaving her room to track down staff members to assist her roommate. She further stated there are occasions in which staff answer the call light but don't provide assistance before leaving, requiring her to press her call button again and wait for someone to respond. The Annual MDS for Resident #10, dated 01/08/2025, which documented her BIMS score as 15, indicating intact cognition. An interview on 01/28/2025 at 07:36 PM 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 staff interview, staffing file review, and facility document review the facility failed to have adequate nursing staff and had the Director of Nursing (DON) working the floor in a facility with a census greater than 60. The facility reported a census of 78. Findings include: Review of staffing files dated 12/01/2024 to 12/26/2024 revealed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) scheduled to work the nursing floor on 10 occasions during the reviewed period. In an interview on 01/29/2025 at 02:37 PM with the former Director of Nursing (DON), she noted she was working the floor three times a week or more from a period of time lasting from November 2024 until December 2024 when she quit. She cited working full time as a PM nurse as the reason she ultimately left the facility. She noted she experienced burnout due to the high demands placed on her, and began to worry about her license. She originally gave notice but left early after the facility continued to ask she work as a full time PM nurse in addition to her DON duties. She was unaware that…

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

Based on observations, food temperatures during food services, resident interview, and facility policy review, the facility failed to serve food within appropriate temperature ranges during 1 of 1 meal observed. The facility reported a census of 78. Findings include: In an interview on 01/28/2025 at 08:15 PM with Resident #13, she stated that while she typically enjoys the food it is often served to her cold and she has to microwave it to make it warm. She stated that while she is ambulatory and can heat food herself, she worries that it is not as easy for other residents in the facility. She typically requests a room tray. Her brief interview for mental status (BIMS) is noted as 15, indicating intact cognition. In an interview on 01/28/2025 at 07:36 PM with Resident #10, she stated the food is often cold and not to her liking. As a result, she has requested her husband take her home for dinner during most evenings. Her BIMS score is noted as 15, indicating intact cognition. In an interview on 01/27/2025 at 12:40 PM with Resident #16 she stated the food is often bland and not always…

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 interviews and policy review the facility failed to provide adequate nursing supervision for one of three residents reviewed who had high fall risk. The facility also failed to perform and document findings of root cause analysis after a resident had a fall to help determine the reasons for a resident's fall, and in order to prevent further falls for one of three residents reviewed for falls (Resident #7). The facility also failed to ensure fall interventions were added to the resident's Care Plan for one of three residents reviewed for falls. The facility reported a census of 78 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had diagnoses of anemia, atrial fibrillation, cardiac pacemaker, muscle weakness and repeated falls. The MDS assessment revealed the resident had a Brief Interview for Mental Status score of 3, which indicated severely impaired cognition. The MDS recorded the resident required partial to moderate…

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 facility policy review, the facility failed to notify the Ombudsman of a resident transfer to the hospital for 5 of 5 residents reviewed. Resident #29, #9, #57, #50, and #85. The facility reported a census of 86. Findings include: 1. A facility census report for Resident #29 documented he was hospitalized on [DATE] and was readmitted to the facility on [DATE]. The facility progress notes for Resident #29 dated from 01/14/24 to 01/16/24 which indicated the resident was sent to the emergency room (ER) on 01/14/24, admitted to the hospital, and readmitted to the facility on [DATE]. The facility did not provide proof of ombudsman notification. 2. A facility census report for Resident #9 which revealed he was hospitalized on [DATE] and was readmitted to the facility on [DATE]. The facility progress notes for Resident #9 dated from 01/11/24 to 01/18/24 which indicated the resident was sent to the ER on [DATE], admitted to the hospital, and readmitted to the facility on…

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

Based on resident interview, direct observation, staff interview, family interview, and facility document review, the facility failed to provide sufficient staff to provide needed cares and supervision to ensure safety of residents at the facility. The facility reported a census of 86. Findings include: 1. A direct observation on 06/11/24 at 08:41 PM revealed Resident #9 wandering the hallway of the facility without staff in sight. Resident #9 wheeled himself into the activities room and was unobserved by facility staff for a period of time from 08:41 PM until staff checked on him at 09:37 PM. Review of Resident #9's care plan at the time of the incident indicated that Resident #9 was on 15-minute checks. In an interview on 06/12/24 at 03:00 PM the Director of Nursing (DON) acknowledged the resident had not had staff eyes on for a period of 56 minutes. In an interview on 06/13/24 at 03:02 PM with the Administrator, she stated that the only staff members who have access to internal security camera footage are herself, the DON, and the Director of Maintenance. On 06/13/24 at 03:15 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 observations, record review, staff interview, and facility policy review, the facility failed to ensure complete and accurate records kept, and failed to provide access to electronic health records in a timely manner in order to facilitate an efficient survey process. The facility reported a census of 86 residents. Findings include: 1. On 06/10/24 at 08:40 AM, the Director of Nursing (DON) stated they used the On-Base software system for storing resident documents. At the time, the DON stated she would get facility computers set up for the surveyors. On 06/10/24 at 9:17 AM, the surveyor sent an email to the Administrator with survey documents and items needed for survey, including access to all resident medical records (paper, electronic health records (EHR), etc.) On 06/10/24 at 10:15 AM, the surveyor met with the Administrator and requested access to the EHR's, which included access to On-Base resident records/documents. The Administrator stated she needed to get a couple of computers set-up so the surveyors could access the residents' medical records and documents. On…

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

Based on record review, resident and staff interviews, review of the facility's grievance/concern forms, and policy review, the facility failed to make efforts to investigate and follow up on the residents' concerns regarding missing cigarettes for 3 of 4 residents reviewed for missing belongings. The facility reported a census of 86 residents. Findings include: In a confidential resident interview 06/10/24 at 2:15 PM, one resident reported concerns about her cigarettes getting taken. She bought a carton of cigarettes 3-4 months ago and the carton came up missing. The resident stated the cigarettes are kept at the Lilac nurse's station in a locked room requiring a keycode to enter. The resident stated she reported the cigarettes missing but no cigarettes were found. The resident reported the problem (of cigarettes missing) had gotten worse because other residents had their cigarettes taken too. She reported her concern to the social worker (SW) and other staff at the facility. In an interview 06/10/24 at 03:30 PM, another resident reported a concern for missing cigarettes. 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 interview, and policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one of eighteen resident's reviewed in the sample (Residents 64). The facility reported a census of 86 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had diagnoses of adjustment disorder with anxiety, mood disorder, bipolar disorder, and depression. The MDS indicated the resident not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS documented the resident admitted to the facility on [DATE]. The Care Plan revised 4/1/24 revealed Resident #64 had diagnoses of adjustment disorder, anxiety, depression, bipolar disorder, and dementia. The resident had behaviors such as yelling at staff, non-compliance with cares, stealing cigarettes and lighters, and took antipsychotic and antidepressant 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility record review, staff interview, and policy review, the facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for 1 of 5 residents screened (Resident #37). The facility also failed to develop a resident's comprehensive care plan and ensure Pre-admission Screening and Resident Review II service recommendations added to the resident's comprehensive care plan for 1 of 5 residents reviewed (Residents #64). The facility reported a census of 86 residents. Findings Include: 1. The Minimum Data Sample (MDS) for Resident #37, dated 06/11/24, indicated a brief interview for mental status (BIMS) interview could not be completed as the resident is rarely or never understood. The MDS revealed relevant diagnoses of aphasia, non-Alzheimer's dementia, Parkinson's disease, depression, psychotic disorder, schizophrenia, post traumatic stress disorder. Review of a PASRR for Resident #37, dated 10/09/2019, did not include the diagnoses of schizophrenia, or depression. In an email…

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, review of facility bath records, resident and staff interviews, and policy review, the facility failed to ensure residents' groomed and received their scheduled baths for two of eight residents reviewed for bathing (Resident #50 and #64). The facility reported a census of 86 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 50 had diagnoses of Parkinson's Disease, diabetes, and dementia. The MDS documented the resident required substantial to maximum assistance for bathing and personal hygiene. The Care Plan revised 3/27/24 revealed the resident had a self- care deficit in activities of daily living (ADL's) related to Parkinson's Disease, vascular dementia, and Tourette's disorder. The care plan directed staff to provide extensive assistance of one for bathing and limited assistance of one for personal hygiene. During observations 6/10/24 at 11:30 AM, Resident#50 sat in a wheelchair across from the nurse's station.…

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 and facility policy the facility failed to document assessments, interventions, and treatments for 1 of 3 residents reviewed for skin management concerns. The facility reported a resident census of 86. Findings include: 1. The MDS assessment dated [DATE] revealed Resident #64 had diagnoses of sepsis (infection), diabetes, Stage 2 pressure ulcer to the left heel, chronic ulcer to the left foot, and an unstageable pressure ulcer to the right heel. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating cognition intact. The MDS indicated the resident took an antibiotic during the 7-day look-back period. The Care Plan revealed the resident had a left heel ulcer and a pressure ulcer to the right plantar foot. The resident required Enhanced Barrier Precautions (EBP). The staff directives included perform treatments per the physician's orders. Review of the treatment record (TAR) 4/1/24 to 6/10/24 revealed treatments not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to attempt non-pharmacological and behavioral interventions prior to the use of or in conjunction with antipsychotic medication use for one of four residents reviewed for unnecessary medications (Resident #50). The facility reported a census of 86 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 50 had diagnoses of Parkinson's Disease, dementia, Tourette's syndrome, and repeated falls. The MDS documented the resident had no hallucinations, delusions, or behaviors. The MDS documented the resident took antidepressant and had no psychological therapy during the 7-day look-back period. The Care Plan revised 3/27/24 revealed the resident had vascular dementia, Tourette's disorder, and a mood disorder. The resident took a psychotropic medication. The care plan directed staff to monitor resident condition and medication side effects. The Care Plan documented a focus area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and policy review. The facility failed to ensure staff changed gloves and sanitized hands in accordance with proper infection control techniques when contaminated to protect against cross contamination and potential infection for one of five residents observed for treatments/dressing changes (Resident #64). The facility reported a census of 86 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had diagnoses of sepsis, diabetes, chronic left foot ulcer, and an unstageable pressure ulcer on the right heel. The MDS indicated the resident took an antibiotic during the look-back period. The Care Plan updated on 4/29/24 revealed the resident had a left heel pressure ulcer and impaired skin integrity. The resident required Enhanced Barrier Precautions (EBP). The staff directives included a weekly skin observation by a licensed nurse and treatments as ordered. The Physician's Order Summary report revealed…

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 investigation file, staff interviews, and policy review, the facility failed to ensure staff appropriately completed a resident assessment and provide timely intervention when a resident exhibited signs and symptoms of a stroke for 1 of 4 residents (Resident #6) who had a change in condition. The facility reported a census of 73 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation (irregular heart beat), and respiratory failure. The MDS dated [DATE] revealed the resident had an unplanned discharge to the hospital on [DATE]. The Care Plan initiated and revised on 12/12/23 revealed the resident had a communication problem related to a hearing deficit, and resisted cares at times. The Progress Notes revealed the following: a. On 12/1/23 at 5:44 PM, Resident #6 admitted to the facility from the hospital. Resident alert and oriented…

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 facility policy review, the facility failed to ensure staff maintained accurate records for the administration of controlled substance medications for 1 of 3 residents (Resident #4) reviewed for use of controlled substances. The facility reported a census of 73 residents. Findings include: A self-report from the facility to the Department of Inspections, Appeals and Licensing (DIAL) submitted on 10/18/23 at 8:02 AM, revealed the facility staff unable to account for two doses of Oxycodone 10 milligrams (mg). The doses were signed out by an agency nurse on 10/12/23 at 6:55 PM and 11:45 PM. The resident was in the hospital at the time, and later discharged home to hospice. The discrepancy was noticed on 10/16/23 when the nurses destroyed the resident's narcotics. The facility initiated an investigation and notified the police. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 admitted to the facility on [DATE] and had diagnoses 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.