Iowa City Rehab & Health Care

Based on clinical record review, policy review, and staff interviews, the facility failed to assess a dialysis (a treatment which filters waste and fluid from the blood when the kidneys failed) access site (a surgically created location allowing blood removal and return for cleansing) on non-dialysis days for 1 of 1 residents reviewed for dialysis care (Resident #8). The facility reported a census of 47 residents.Findings include:The Minimum Data Set (MDS) assessment tool, dated 4/23/26, listed diagnoses for Resident #8 which included end stage renal (kidney) disease, blindness, and abnormalities of breathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 1/25/25 Care Plan entry directed staff to complete a dialysis flow sheet daily to observe for access site complications.The April and May 2026 Medication Administration Records (MARs) directed staff to assess the resident's dialysis access site on Mondays, Wednesdays, and Fridays(dialysis days) to check for signs and symptoms of infection or bleeding.…

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 review, policy review, and staff interview, the facility failed to verify Certified Medication Assistant (CMA) certification validity prior to hire for 1 of 1 newly hired CMAs. The facility reported a census of 47 residents. Findings included:1. The facility undated New Hire List and Roster listed a hire date for Staff J CMA as 8/14/25.The facility lacked documentation of verification of Staff J's CMA certification. The facility policy License Verification, revised 2025, stated the facility would verify all personnel certifications.On 5/7/26 at 11:36 a.m., the Director of Nursing(DON) stated CNA verification and criminal background checks should be done before hire.

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 prescribed stock medications were available for 2 of 4 residents (Resident #6 and Resident #2) reviewed for medication administration. The facility reported a census of 47 residents.Findings include:1. Review of Resident #6's April 2026 Medication Administration Record (MAR) revealed the following orders:a. MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth in the morning for Constipation. The MAR indicated Miralax scheduled to be administered in AM.A review of the April 2026 MAR revealed a code of 11 used for the AM scheduled Miralax on 4/27/26, 4/28/26, 4/29/26, and 4/30/26. Per the MAR Chart Codes, the use of an 11 indicated Med not available.b. Lidocaine External Patch (Lidocaine) Apply to lower back topically two times a day for pain, 4% OTC (over the counter). The MAR indicated the patch to be ON 0800 (8:00 AM) and OFF 2000 (8:00 PM). A review of the April 2026…

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 resident and staff interviews, the facility failed to ensure call lights functioned or were within reach for 2 of 24 residents reviewed for call light accommodations (Residents #1 and #11). The facility reported a census of 47 residents.Findings included:1. The Minimum Data Set (MDS) assessment tool, listed diagnoses for Resident #1 which included heart failure, depression, and alcohol dependence. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition.On 5/4/26 at 10:46 a.m., Resident #1 stated his call light stopped working 3 weeks ago.On 5/4/26 at 11:24 a.m., Staff F, Registered Nurse (RN) pushed the resident's call light and it did not turn on. When she tried it a second time, it turned on but when she tried it a third time, it did not work. On 5/5/26 at 1:48 p.m., the Maintenance Director stated staff did not report that Resident #1's call light did not work prior to yesterday. He stated a new part was needed in order to fix it.On 5/7/26 at 8:10…

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 review, policy review, and staff interview, the facility failed to ensure 1 of 5 staff members reviewed for Dependent Adult Abuse(DAA) Mandatory Reporter's Training had current training. The facility reported a census of 47 residents.Findings included:The facility undated New Hire List and Roster listed a hire date for Staff J Certified Medication Aide as 8/14/25.Staff J's personnel file lacked documentation of a DAA Mandatory Reporter's Training completed within 6 months of hire. On 5/7/26 at 9:20 a.m, Staff H Interim Administrator stated that he had no other employee file documentation. He stated he was aware there were concerns with the files.The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated 3/18/26, stated the facility would carry out criminal record checks on all prospective employees and stated within 6 months of hire, each employee was required to complete 2-hour DAA training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and staff interviews, the facility failed to maintain the head of the bed elevated during a continuous tube feeding and failed to apply an abdominal binder per physician order for 1 of 1 resident (Resident #1) reviewed for g tube feedings. The facility reported a census of 45 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99 [a code used to indicate an incomplete interview]. The MDS list of diagnosis included paraplegia, non-Alzheimer's dementia and malnutrition. The MDS indicated Resident #1 had a gastric tube with tube feedings continuously.A review of the Care Plan, dated 9/22/25, revealed Resident #1 with the problem of being at risk for altered nutritional status as he was dependent on tube feedings to meet estimated needs. A review of Physician orders revealed:a. Percutaneous Endoscopic Gastrostomy (a tube placed into the stomach for 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, facility policy review, and staff interviews, the facility failed to ensure routine medications were re-ordered prior to the exhaustion of the supplying causing 1 of 4 residents (Resident #2) to miss three full days of medications. The facility reported a census of 45 residents.Findings include:Review of the Minimum Data Set (MDS) dated [DATE], identified Resident #2 with a moderate cognitive impairment based on a BIMS (Brief Interview for Mental Status) score of 11 out of 15. The list of diagnoses included Alzheimer's disease, diabetes mellitus, thyroid disease and atrial fibrillation (irregular heart beat). The MDS documented an admission date of 12/08/2026. Review of the electronic health record (EHR) revealed an ED (Emergency Department Note) dated 1/3/26 which revealed, in part: Chief Complaint.Pt from [name of facility redacted]. Daughter called EMS (emergency medical services) regarding pt cares. Pt missing appointments and medications stopped without explanation. Daughter…

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, facility policy review, and staff interviews, the facility failed to provide a safe, clean, and homelike environment for the residents. The facility reported a census of 43 residents.Findings include: During an interview on 12/9/25 at 10:00 AM, Staff A, Transportation/Maintenance, while in the hopper room with a contracted plumber, stated the hopper (a specialized, large sink with a toilet- like flush used for hygienic disposal of body waste) is in need of repairs. Staff A stated the hopper had been out of order for a while and the facility initiated the process of getting bids to repair it. Staff A also stated floors in the facility needed cleaning and strippingOn 12/9/2025 from 10:10 AM to 10:30 AM, the following environmental concerns observed:a. In room [ROOM NUMBER], the heating/air conditioner unit on the wall under the window had a moderate amount of rust and missing paint.b. In room [ROOM NUMBER], the floor had a heavy buildup of dirt/dark substance throughout. The heating/air…

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 administer medication as the physician prescribed for 2 of 3 residents reviewed (Resident #2, #3). The facility reported a census of 43 residents. Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had no cognitive impairment based on Brief Interview for Mental Status (BIMS) score of 13 out of 15. The list of diagnoses included chronic obstructive pulmonary disease (COPD), chronic pain, and diabetes.During an interview on 12/9/25 at 9:00 AM, Resident #2 stated she did not receive pain medication on 12/7/25 for approximately 20 hours. Resident #2 stated she knew the medication would run out and was told not to worry. Resident #2 stated on 12/7/25 she received a dose at 3:00 AM, and the next dose at 9:00 PM. Resident #2 stated she did receive an alternative medication but it was not effective. Review of the December 2025 Medication Administration Record (MAR)…

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 reviews, resident and staff interviews, the facility failed to provide a restorative program for 3 of 3 residents (Resident # 1, #3, #4) at risk of physical decline related to diagnosis and risk of falls. The facility reported a census of 43 residents. Findings include1. Review of the Minimum Data Set (MDS), dated [DATE] for Resident #1 revealed the resident ambulated independently and had diagnoses of chronic obstructive pulmonary disease (COPD), pain and diabetes. Review of Resident #1 Care Plan, date revised 10/24/25 revealed a Focus area to address [Name redacted, Resident #1] is at risk of falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment and/or the use of medications that may increase falls risks related to dx (diagnosis) of chronic pain, DM2 (diabetes), HTN (hypertension), CKD4 (chronic kidney disease stage 4), incontinence, and drug induced akathisia (movement disorder). Interventions included, 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 observation, resident and staff interviews and record review, the facility failed to have sufficient staff to meet the needs of the residents. The facility reported a census of 43. Findings include: During a continuous observation on 12/8/2025, the call light for room [ROOM NUMBER] activated at 10:40 AM, and remained on until answered at 10:58 AM. During a continuous observation on 12/9/2025, the call light for Resident #6's room (#42) activated at 12:15 PM. The resident observed in bed, lying on her right side with her head against the side rail. The resident's lunch tray sat on the bedside table near the bed. At 12:38 PM, the call light turned off. At 12:40 PM, during an interview, Resident #6 stated Staff B, Nurse Practitioner helped her. The resident positioned in the bed, with the head of the bed elevated, and her head rested on a pillow. The resident began to eat lunch. Staff B stated the resident prefers to eat in her room, in bed. During an interview on 12/9/25 at 12:45 PM, Staff C, Certified…

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, facility policy review, facility staff interviews and physician/provider interviews, the facility failed to follow physician orders for 2 of 7 resident records reviewed (Resident's #1 and #5), failed to complete appropriate wound condition assessments (Resident's #1 and #5), and documented that physician ordered dressing/wound care treatments were completed as prescribed over a 4 day period, when the prescribed wound care treatments were not completed or attempted, for 1 of 3 residents reviewed with wounds (Resident #5). The facility reported a census of 44 residents.Findings include:1.The 7/21/25 admission Minimum Data Set (MDS) Assessment tool revealed Resident #5 admitted to the facility 7/17/25 with diagnoses that included peripheral vascular disease, renal failure, abdominal aortic aneurysm without rupture, postprocedural shock unspecified, initial encounter, dependent on staff to reposition, transfer, toilet, dress and bathe, unable to stand or ambulate, and substantial staff assistance required to sit from lying and to lie from a…

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

Based on observation, policy review, and staff interviews, the facility failed to provide a homelike environment for residents when staff used a nicotine vape pen in the common areas of the facility. The facility reported a census of 46 residents. Findings include: Observations during the survey week of 5/5/25 to 5/8/25 revealed an outdoor smoking area located off the dining room. During an interview on 5/7/25 at 12:24 PM, Staff E, Certified Nursing Assistant (CNA) stated she caught Staff H, Activities staff vaping in her office. She stated her office was off the dining room and her door was open. She stated there were residents in the dining room at the time. During an interview on 5/7/25 at 12:49 AM Staff F, Certified Medication Assistant(CMA) stated Staff H inside her office and also during bingo while she sat right next to residents. She stated Staff C, Office Staff also vaped in her office. During an interview on 5/8/25 at 11:32 AM, the Director of Nursing (DON) stated she observed Staff H vape in her office and directed her to stop doing this. She stated the Administrator…

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

Based on observation, clinical record review, and staff interview, the facility failed to assess and care plan for a resident to self-administer medications (Resident #42) for 1 of 6 residents reviewed for medications. The facility reported a census of 46 residents. Findings included: The Minimum Data Set (MDS) assessment tool for Resident #42, dated 4/25/25, list of diagnoses included: heart failure, diabetes, and shortness of breath. The Brief Interview for Mental Status (BIMS) score 14 out of 15 indicated intact cognition. Review of the Care Plan, Date Initiated: 11/1/24 included a Focus area to Address {Name redacted} is on diuretic therapy (medications used to treat fluid retention) r/t (related to) hypertension. Review of the May 2025 Medication Administration Record (MAR) revealed a 1/21/25 order for bumetanide (a diuretic) 1 milligrams(mg) twice daily at am and lunch. During an observation on 5/5/25 at 12:07 PM, Resident #42 laid in bed and had a pill in a medication cup in front of him on his bedside table. The resident stated it was a pill to make him urinate. He stated…

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

Based on clinical record review and staff interview, the facility failed to provide a notice of Medicare Non-Coverage upon discharge from skilled nursing services to 1 of 3 residents reviewed (Resident #45). The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) Discharge Assessment for Resident #45, dated 5/1/25, identified the resident had a planned discharge from Part A, Medicare services, and discharged to the resident's home. The MDS revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated intact cognition. The MDS indicated Resident #45 capable of independently understanding written instructions. During an interview on 5/6/25 at 10:45 AM, the Administrator reported an inability to find a Notice of Medicare Non-Coverage (NOMNC) for Resident #45. The Administrator reported Staff B, Social Worker (SW), took over the responsibility of completing the Advance Beneficiary Notice (ABN) and NOMNC with residents from the business office staff recently; approximately 2 weeks after the social worker started on 3/7/25. The…

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

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to assess the resident and notify the physician after 1 of 3 residents' (Resident #9) self-reported seizure activity. The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) Assessment, dated 2/06/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS list of diagnoses included: seizure disorder, multiple sclerosis, cerebrovascular accident (CVA or stroke), schizophrenia, and depression. The MDS identified Resident #9 took anticonvulsant (anti-seizure) medications. Review of the Care Plan, Date Initiated: 7/24/14, Revision on: 2/11/25 revealed a Focus area to address [Name redacted] has a seizure disorder r/t (related to) Epilepsy. Interventions directed, in part: a. POST SEIZURE TREATMENT: Turn on side with head back, hyper-extended to prevent aspiration, Keep airway open, After seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC (level of…

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

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure a resident positioned in a safe manner when eating for 1 of 2 residents reviewed for positioning (Resident #25). The facility reported a census of 46 residents. Findings included: 1. The MDS assessment tool for Resident #25, dated 2/21/25, list of diagnoses included: hemiplegia (one-sided paralysis), cerebral infarction (stoke), and difficulty walking. The BIMS score of 10 out of 15 which indicated moderately impaired cognition. Review of the Care Plan, Date Initiated: 3/1/22 revealed a Focus area to address [Name redacted] has potential for altered nutritional status AEB PMHx of CI (as evidenced by past medical history of cerebral infarction), hemiplegia, anemia, hx of mild protein-calorie malnutrition dysphagia (difficulty swallowing). During an observation on 5/5/25 at 11:57 AM, Resident #25 laid in bed with a tray of food on a bedside table on the side of the bed. The head of the bed was less than 15 degrees. When interviewed, Resident #25 stated she could eat in 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, clinical record review, facility policy review, resident and staff interviews, the facility failed to develop and implement interventions to attempt to restore or improve bladder function for 1 of 1 residents reviewed for urinary incontinence (Resident #42); and the facility failed to ensure a urinary catheter collection bag and tubing secured in a manner that prevented contact with the floor in a an attempt to prevent the potential for a urinary tract infection for 1 of 2 residents (Resident #8) reviewed with catheters. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 4/25/25, diagnoses list for Resident #42 included; heart failure, diabetes, and shortness of breath. The MDS stated the resident was always incontinent of urine and frequently incontinent of bowel. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, which indicated intact cognition. The MDS stated the facility did not carry out a trial of a toileting program. Review of the Care Plan,…

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

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure residents were free from significant medication errors by not priming an insulin pen prior to the administration of the medication for 1 of 1 resident (Resident #22) reviewed for insulin. The facility reported a census of 46 residents. Findings: The Minimum Data Set (MDS) assessment tool, date 4/9/25, listed diagnoses for Resident #22 which included diabetes, depression, and lack of coordination. The MDS indicated Resident #22 received insulin injections 7 of the 7 days during the review period. During an observation on 5/7/25 at 11:34 AM, Staff A Licensed Practical Nurse (LPN) obtained a blood sugar on Resident #22 which measured 209 mg/dl. Staff A then dialed up four units on the resident's Humalog KwikPen and stated she was ready to inject the medication. Staff A stated she did not prime the pen because on this type of pen, it was only required to prime during the first use. Staff A proceeded to inject the resident with four units of insulin from the pen. Review 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.

Based on clinical record review, staff and resident interviews and observations the facility failed to employ an Infection Prevention Specialist. The facility reported a census of 45. Findings include: Observation of a facility provided list of all staff on 3/3/25 at approximately 10:00 am failed to include an Infection Prevention Specialist or and Infection Control Nurse. During an interview with Staff F-Administrator on 3/4/25 at 9:00 am, she stated that approximately 1 month ago she lost her Director of Nurses and Assistant Director of Nurses. She stated the Assistant Director of Nurses did the infection control for the facility and she did not have anyone to fulfill this role as she left. Staff F stated she has not been able to find an appropriate replacement for the Infection Control Nurse until yesterday.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review and staff interviews, the facility failed to follow standard and transmission-based precautions to prevent spread of infections for 4 of 4 residents reviewed. (Resident #2,#3,#4,#5). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had no cognitive impairment, transferred from one surface to another with a mechanical lift, had a surgical wound and diagnoses including orthopedic conditions, viral hepatitis, complete amputation right foot, frostbite hand, and skin graft. The resident's Care Plan identified a Focus area that required EBP (Enhanced Barrier Precautions) related to the presence of skin grafts/frostbite wounds to bilateral hands/feet and incision site to LBKA (below the knee amputation) initiated 2/6/2025. The Care Plan directed staff to use EBP during completion of high contact activities, adhere to the use of EBP once instituted, and protection will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident council minutes, call light logs, staff and resident interviews the facility failed to answer resident's call lights within 15 minutes for 4 of 4 activated call lights reviewed. The facility reported a census of 44. Findings include: On 1/13/25 at 7:40 am, 4 call lights observed blinking (activated by residents to request assistance) on the East Hall, for rooms 31, 37, 38 and 45. Staff A, Licensed Practical Nurse (LPN) noted to be passing medications to residents in the East Hall. When interviewed, Staff A stated she is the only staff person on that wing at this time because the aide who was scheduled to come in at 6:00 am had not arrived to work yet. She stated the aide will be coming but does not know when she will arrive. Observation on 1/13/25 at 7:30 am, revealed Staff B, Certified Nursing Assistant (CNA) arrived to work, stating she had car troubles this am which made her late. During an interview on 1/14/25 at 11:30 am, Resident #6 stated the staff sometimes do not answer…

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

Based on observation, staff interview and policy review, the facility failed to ensure proper personal hygiene practices to prevent contamination of food when staff failed to wear beard guards while in the kitchen area. The facility reported a census of 46 residents. Findings include: In an observation on 7/16/24 at 2:45 PM, 2 male dietary employees were noted to be working in the kitchen area with hair nets on but no beard guards in place to cover their facial hair. In an interview on 7/16/24 at 2:55 PM, the Dietary Manager stated it was the expectation that facial hair be covered. He reported he hadn't noticed the staff were not wearing the beard guards. They have the beard guards available and he would have the staff start wearing them. He stated they had worn them in the past. A facility provided policy titled Sanitation - Personal Hygiene, stated the staff were to wear hair restraints at all times and beard guards were to be worn by all male employees with facial hair.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy review, and staff interview the facility failed to uphold resident rights and dignity for 1 of 1 residents reviewed on hospice care. The facility identified a census of 46 residents. Findings include: Resident #17 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15 indicating severe cognitive loss. The Resident required substantial to maximal assistance (the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort) for eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid one the meal is placed before the resident). The MDS documented diagnoses of cerebrovascular accident (CVA) with hemiparesis (a condition that causes partial paralysis or weakness on one side of the body), generalized muscle weakness, cognitive communication deficit, and the presence of hospice care services. The Care…

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 and resident interviews, and policy review, the facility failed to provide services that met professional standard regarding medication administration and following physician orders for 2 of 9 residents reviewed (Resident #31 and #32). Staff failed to monitor and stay with residents who did not have an order for self-medications to ensure the medications were taken as ordered. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. The MDS further documented the resident had diagnoses including cerebral infarction, cognitive communication deficit, and dysphagia. In an observation on 7/15/24 at 11:35 AM, a medication cup with 2 white tablets was noted on Resident #31's bedside table. Resident #31 reported the medication was Tylenol. Resident #31 reported the staff thought she was going…

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 protect a resident from hazards in the environment for 1 of 1 resident sampled when Resident #4 acquired first degree burns from spilt coffee and failed to ensure a resident was properly assessed to be independent to smoke, followed the facility smoking policy and discarded cigarette butts into a proper receptacle (Resident #28). The facility identified a census of 46 residents. Findings include: 1. Resident #4 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 2 indicating a severe cognitive impairment. The resident exhibited inattention (being easily distractible/difficulty keeping on track of what is said) that fluctuated; continuously present disorganized thinking (rambling or irrelevant conversation, unclear, illogical flow of ideas, or unpredictable switching from subject to subject); delusions; physical behavioral symptoms directed toward others…

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, and staff interview the facility failed to provide appropriate catheter care to prevent potential cross contamination that could lead to a urinary tract infection (UTI) for 2 of 2 residents sampled (Resident #17 and #41). The facility identified a census of 46 residents. Findings include: 1. Resident #17 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 1 indicating severe cognitive impairment with a diagnosis of cerebrovascular accident (CVA) with hemiplegia (a symptom that causes paralysis or severe weakness on one side of the body). The MDS documented Resident #17 as dependent upon staff for managing his urinary catheter for a diagnosis of neurogenic bladder. The Care Plan revised 2/20/23 documented the use of a suprapubic catheter and directed the staff in the following: a. The Resident's suprapubic catheter changed at the urology clinic monthly. Date Initiated 3/06/2024. b. The Resident has an 18 French…

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, record review, and facility policy review, the facility failed to document if the resident's emergency contact picked up the resident personal possessions after his death for 1 of 5 residents reviewed for personal possessions (Resident #7). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The Progress Note dated [DATE] at 10:52 PM, revealed the medical examiner called and said that the resident was deceased at the ER (Emergency Room). The Progress Note dated [DATE] at 11:29 PM, revealed the nurse able to get in contact with the emergency contact at 11:20 AM. Emergency contact said that the hospital already called and informed her of the resident's passing. Emergency contact requested that all the valuables and belongings be kept for her to pick up tomorrow. She also would like a copy 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 observation, interview, record review, and facility policy review, the facility failed to perform complete incontinent cares following urinary incontinence for 1 of 3 residents reviewed for incontinent cares (Resident #15). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicative of severe cognitive impairment. Resident #15 required dependence on staff for toilet hygiene, dressing, personal hygiene, and transferring. Diagnoses included dementia with behavioral disturbance and End-Stage Renal Disease. The Care Plan, revised 02/16/24, revealed Resident #15 had a focus area for mixed bladder incontinence related to dementia with interventions to check resident as required for incontinence and wash, rinse, and dry perineum (vaginal and rectal areas), and change clothing as needed after incontinence episodes. The Weekly Skin Assessment, dated 02/21/24,…

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, interviews, and the facility policy, the facility failed to ensure all of the residents were accounted for after they responded to and turned off a door alarm, which resulted in an elopement of a resident for 1 of 4 residents reviewed for adequate supervision of residents (Resident #5). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident independent with walking 150 feet in a corridor or a similar space. The MDS revealed diagnoses of anxiety disorder, depression, and schizophrenia (e.g. schizoaffective and schizophreniform disorders). The Care Plan revealed a focus area dated 12/20/23 for high elopement risk/wanderer related to impaired safety awareness and a lack of impulse control. The interventions dated 12/20/23 revealed distract resident from wandering/exit…

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

Based on clinical record review, observations, staff and resident interviews, and facility policy review, the facility staff failed to ensure 1 out of 15 residents who smoked was smoking in a designated area, used the appropriate receptacles for discarding cigarette butts and failed to ensure the safety of all residents when the identified resident, with cognitive impairment and symptoms of delirium present, smoked in their resident room on repeated occasions (Resident #1). The facility reported a census of 46 residents. Findings Include: The 7/13/23 Minimum Data Set (MDS) Assessment Tool documented Resident #1 admitted to the facility 6/21/23 with diagnoses that included cancer with malignant neoplasm, intestine perforation, conduct disorder and left ankle and foot pain, scored 11 out of 15 possible points on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated mild cognitive impairment. The MDS identified the resident with symptoms of delirium that included disorganized thoughts and inattention, always present and fluctuated in severity, and the…

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

Based on clinical record review, resident, staff and Pharmacist interviews, and facility policy review, the facility staff failed to order a resident's narcotic pain medication in a timely manner that causing an interruption of continuous pain management and control for 1 of 2 residents reviewed (Resident #1) that required Fentanyl (a very strong narcotic analgesic), and failed to notify the Physician/Provider of record of the resident's repeated increased severe pain ratings and seek appropriate interventions that addressed the increased pain level. The facility reported a census of 46 residents. Findings Include: The 7/13/23 Minimum Data Set (MDS) Assessment tool revealed Resident #1 admitted to the facility 6/21/23 with diagnoses that included cancer with malignant neoplasm, rectal and anal hemorrhage, intestine perforation, and left ankle and foot pain, scored 11 out of 15 possible points on the Brief Interview for Mental Status (BIMS) cognitive assessment indicating mild cognitive impairment, and the resident always able to make herself understood and always able to understand…

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.