Accura Healthcare of Lake City, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to provide bathing assistance for 2 of 2 residents reviewed for bathing (Residents #1 and #13). The facility reported a census of 41 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS did not document or code how much assistance Resident #1 required for bathing. Resident #1's MDS included diagnoses of peripheral vascular disease, diabetes mellitus, non-alzheimer's dementia, and an unstageable pressure ulcer to buttocks. The Care Plan with a target date of 8/12/25 documented Resident #1 required assistance of one staff member with bathing or showering. The facility form titled Bath Schedule documented Resident #1 was scheduled for a bath on Monday and Wednesday. The facility electronic from titled Shower/Bath Self for the last 30 days documented Resident #1 received a bath/shower on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility policy the facility failed to put proper interventions in place to prevent a stage 2 pressure ulcer to the right heel consistent with professional standards of practice for 1 of 1 residents reviewed (Resident #38). The facility reported a census of 41 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones 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 exposed. Slough may be present but…

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 and policy review, the facility failed to put effective interventions in place and provide adequate nursing supervision to prevent accident and injuries from falls for 1 of 1 residents reviewed (Resident #18). Resident #18 had a risk for falls with a history of repeated falls. Resident #18 had his thirteenth fall on 3/5/25 in a three-month period of time. On 1/9/25 Resident #18 had an unwitnessed fall in his room, resulting in a fracture to his left hand. Findings include: Resident #18's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS listed Resident #18 as independent with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfers. The MDS listed Resident #18 as supervision for toileting. The MDS described Resident #18 as frequently incontinent of urine. Resident #18's MDS included diagnoses of non-traumatic…

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 complete a gradual dose reduction (GDR) for 2 out of 5 residents reviewed for unnecessary medications. (Residents #5 and #19). The facility reported a census of 41 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. The MDS identified Resident #5 was dependent on staff for bed mobility, and transfers. Resident #5's MDS included diagnoses of Alzheimer's disease, Non-Alzheimer's disease, multiple sclerosis and depression. The MDS documented Resident #5 was taking antipsychotic and antidepressant medications during the 7 day look back period. The Care Plan with a target date 7/15/25 documented Resident #5 was at risk for adverse effects from antipsychotic and antidepressant medications. The Care Plan directed staff to attempt GDR (gradual dose reduction) per physician…

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, and staff and resident interview, the facility failed to maintain an effective pest control program. The facility reported a census of 46 residents. Findings include: On 1/6/24 at 1:50 p.m. Resident #2 sat in her room in her wheelchair. She said the first time she saw a mouse in her room was sometime in November and she got up and went to her top drawer dresser and opened it. There was a mouse sitting on top of her underwear. It startled her and she fell. She said the second time she saw a mouse in her room is when it came in and got into a sticky trap. Then one of the staff members took it out of the room for her. She didn't know what they did with it and she didn't care. She just couldn't stand the idea of having a mouse in her room. On 1/7/25 at 9:40 a.m. Staff E Certified Nursing Assistant (CNA) stated they have had a mouse infestation. Residents and family had brought it up. She said they had to clean out drawers with mouse droppings in them. It didn't seem to be getting any better. On 1/9/25 7:45 a.m. Staff B Licensed Practical Nurse (LPN) stated there…

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 and staff interview the facility failed to ensure sufficient nursing staff with appropriate training to provide supervision during a meal for 1 of 2 staff reviewed (Staff A). The facility reported a census of 46 residents. Findings include: Staff A's personnel file contained an application dated 9/17/24 showing Staff A worked as a Training Certified Nursing Assistant (CNA) from 8/2024 to 9/2024 at another facility, training to take the CNA test. From 7/2021 to 7/2024 Staff A worked in a restaurant where she served customers food and beverages. Staff A signed the job description for a CNA. A CNA/Nurse Aide-Skills and Competency checklist with a date of hire 8/28/24 (at previous facility) had items dated and checked under met objectives dated 8/31 or 9/3/24. The observer signature identified as the Director of Nursing (DON). The personnel file lacked training by a state approved program or enrollment in a CNA class. In a statement dated 12/5/24 Staff A signed on 12/4/24 she was in the dining room at the end of supper feeding another resident (Resident…

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 and staff interview, the facility failed to ensure an individual applying for a position as a nurse aide could prove that he or she had recently successfully completed a training and competency evaluation program, or was a full time employee in a training and competency program approved by the State for 1 of 2 staff reviewed (Staff A). The facility reported a census of 46 residents. Findings include: Staff A's personnel file contained an application dated 9/17/24 showing Staff A worked as a Training CNA from 8/2024 to 9/2024 at another facility, training to take the CNA test. From 7/2021 to 7/2024 she worked in a restaurant where she served customers food and beverages. Staff A signed the job description for a Certified Nursing Assistant (CNA). A CNA/Nurse Aide-Skills and Competency checklist with a date of hire 8/28/24 (at previous facility) had items dated and checked met objectives dated 8/31 or 9/3/24. The observer signature identified as the Director of Nursing (DON). The personnel file lacked training by a state approved program or enrollment 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.

Based on record review and staff interview, the facility failed maintain a system of drug reconciliation to identify disposition of a missing pill for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 46 residents. Findings include: The Progress Notes dated 9/27/24 at 8 a.m. documented staff reported Resident #4 had a missing Methadone 1/2 tab to equal 2.5 mg. A Self Report documented on 9/27/24 at approximately 6:45 a.m. the Administrator in Training (AIT) received notification from Staff F Registered Nurse (RN) that during narcotic count they noted a discrepancy in Methadone count for Resident #4 of a 2.5 mg tablet of Methadone missing. At Approximately 6 a.m. oncoming Certified Medication Assistant (CMA), Staff G began count of the narcotics in one of the carts and noticed the incorrect count of Methadone for Resident #4. There were only 15 tablets of Methadone, but should have been 16. As of 10 p.m. on 9/26/24 all of the narcotic count was correct and signed off by the off going CMA and oncoming Staff H Licensed Practical Nurse (LPN). A narcotic count…

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 interviews, the facility failed to assess and provide interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 3 residents reviewed (Resident #3). The facility failed to assess and document fall and neurological assessments after an unwitnessed fall for Resident #3. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) for Resident #3 dated 2/28/24 documented a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognition. The MDS identified Resident #3 required partial/moderate assistance with bed mobility, and substantial/maximal assistance with chair/bed to chair transfers. Resident #3 ' s MDS included diagnoses of coronary artery disease, heart failure (heart does not pump blood well), Hypertension (high blood pressure), and renal (kidney) disease. An Incident Report (IR) dated 5/10/24 at 6:30 AM revealed Resident #3 had an unwitnessed fall in her room. The IR documented Resident #3 was sitting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and facility record review, the facility failed to make sure the environment remained free from accident hazards as the door to laundry room was broke and 11 residents that are mobile had access to it and failed to provide adequate nursing supervision for 1 of 1 residents reviewed (Resident #7). The facility reported a total census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of hypertension (high blood pressure), dissociative and conversion disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score was an 8 indicating moderate cognitive impairment. The MDS shows Resident #7 was independent with ambulation and transfers. Observation completed with the Director of Nursing (DON) on 4/2/24 at 12:05 PM of the laundry room door. The door to the laundry does have a key coded pad, but the DON just pushed the door open. The DON did not enter a code to unlock the door. Observed laundry…

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 facility record review, the facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 1 of 1 residents reviewed for abuse who reported a Certified Nursing Assistant (CNA) was being rough with (Resident #2). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses of hypertension (high blood pressure), heart failure, and urinary tract infection. The MDS documented the resident had a brief interview for mental status (BIMS) score of 15, which indicated no cognitive impairment. The Care Plan dated 3/21/24 revealed Resident #2 required assistance of one person with ambulation, bathing, bed mobility, dressing, grooming and toilet use. Interview on 4/2/24 at 3:00 PM with Resident #2 revealed Staff A, CNA entered the room, while I was in bed, Staff A started changing my brief. Staff A rolled me over and pushed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, staff and record review, the facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for 2 out of 2 residents interviewed (Residents #4 and #6). The facility reported a census of 39 residents. Finding included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented the Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS showed Resident #4 required extensive assistance from one person for transfers, bed mobility, dressing and toileting. The MDS diagnosis included hypertension, anxiety disorder, and dehydration. In an interview on 4/2/24 at 10:00 AM, Resident #4 reported she waited for her call light to be answered longer than 15 minutes at least two times. Resident #4 reported that she tracked the time by looking at her watch. Review of the facility call light report named Device Activity Report revealed on 3/31/24 at 8:14 PM it took staff 26…

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 employee file review, facility record review, staff interviews and policy review the facility failed to have cardiopulmonary resuscitation (CPR, life saving measures in case the heart stops beating) certified staff member present on all shifts 24/7. The facility reported a census of 39 residents. Findings include: The facility provided employee CPR (cardiopulmonary resuscitation) certifications listed 9 CPR certified staff members (7 nurses and 2 certified nursing assistants). Review of January and February 2024 nurses' schedules provided by the facility included 11 nurses on the schedules. 2 out of the 3 evening/overnight nurses on the schedule didn't have their CPR certificate. The 2 nurses worked the following dates and times without a CPR certified staff member at the facility: a. [DATE] i. 6 PM to 6 AM - [DATE] - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] ii. 10 PM to 6 AM - [DATE], [DATE] iii. 6 PM to 12 AM - [DATE] b. February 2024 i. 6 PM to 6 AM - [DATE] -…

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 interviews, and policy reviews the facility failed to prepare, serve, distribute, and store food in accordance with professional standards. The facility reported a census of 39 residents. Findings include: On 2/20/24 at 11:31 AM watched the noon meal service, consisting of pork loin (slices), sweet potatoes, vegetables, gravy, and raspberry cake. Staff L, Cook, completed food temperatures and logged the temperatures from the steam table. Hand sanitizer located on the wall before the serving line. Staff L, Staff M, dietary aide, Staff N, Dietary Manager, and 2 unidentified Certified Nursing Assistants (CNAs) served the meal. The staff collected the menu selection from the residents, checked the residents' cards for equipment/diet consistencies, entered the serving line next to the hand sanitizer, obtained selected cold drinks, food items from the steam table, hot drinks from serving dispensers, cake from a serving cart, bread/butter from the counter, and whipped cream placed in an ice container on the counter. Staff M applied gloves without sanitizer,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to have an accurate advanced directive (instructions on what to do in case their heart stops beating or they stop breathing) for 1 out of 16 residents reviewed (Resident #13). Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #13's MDS documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), anemia, heart failure (inability for the heart to pump blood), renal disease, thyroid disorder, arthritis and depression. Resident #13's Clinical Census listed an admission date of [DATE]. Resident #13's Clinical Record included the following code status: Code Status: Do Not Attempt Resuscitation (DNR) and Full code (initiate Cardiopulmonary Resuscitation CPR). The Clinical Physician Orders included the following orders: 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 personnel file reviews, staff interviews, and facility policy review, the facility failed to wait for the completion of a criminal background check prior to start of employment for 2 of 5 current employees sampled Staff I, Certified Nursing Assistant (CNA), and Staff J Licensed Practical Nurse (LPN). Findings include: 1. The personnel file for Staff I documented a hire date of 7/14/23. The Single Contact License and Background Check (SING) indicated Staff I had a possible criminal hit which required the Department of Criminal Investigation (DCI) to clarify whether the prospective employee did or didn't have a criminal history. The personnel record revealed Staff I received clearance on 7/18/23. Staff I's Timesheet indicated she worked the following days prior to 7/18/23. a. 7/16/23: 5:30 AM - 2:00 PM b. 7/17/23: 5:45 AM - 2:00 PM 2. The personnel file for Staff J documented a hire date of 8/17/23. The SING indicated a possible criminal hit for Staff J which required the DCI to clarify if the prospective employee did or didn't have a criminal history. The personnel record…

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 facility policy review the facility failed to provide a notice of bed hold for 2 of 2 residents reviewed (Resident #2 and #19) for discharge to the hospital. Findings include: 1. Resident #2's Minimum Data Set assessment (MDS) dated [DATE] identified Brief Interview for Mental Status (BIMs) score of 11, indicating moderately impaired cognition. Resident #2's MDS included diagnoses of coronary artery disease, hypertension (high blood pressure), diabetes mellitus, non-Alzheimer's dementia, below the knee amputation and depression. The Clinical Census listed Resident #2 discharged to the hospital on 4/7/23. The Transfer to Hospital Summary dated 4/7/23 at 12:08 PM reflected the hospital admitted Resident #2 for pneumonia and a urinary tract infection (UTI). The clinical record lacked documentation the facility provided a bed hold notice to Resident #2 and/or Resident #2's representative upon discharge to the hospital. On 2/21/24 at 7:42 AM, the Director 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 record review, staff interview and Resident Assessment Instrument (RAI) the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment within 14 days of discharge from hospice for 1 of 1 resident (Resident #2) reviewed for hospice services. Findings include: The Clinical Census listed Resident #2 admitted to hospice services on 7/1/23 and discharged from hospice services on 11/11/23. The clinical record lacked documentation of a completed SCSA MDS after Resident #2 discharged from hospice services. The RAI manual; Chapter 2, instructed the facilities to complete a Significant Change in Status Assessment (SCSA) when a resident who is receiving hospice services decides to discontinue those services. The assessment reference date must be within 14 days from one of the following: The effective date of the hospice election revocation The expiration date of the certification of the terminal illness The date of the Physician or medical director's order stating the resident is no longer terminally ill. On 2/20/24 at 11:10 AM, Staff A, 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 clinical record review and staff interviews the facility failed to complete a comprehensive Care Plan for 1 of 2 residents reviewed (Residents #13) with a catheter. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #13 was dependent on staff for toileting transfers and required substantial/maximal assistance with toileting hygiene. The MDS indicated Resident #13 had an indwelling catheter. Resident #13's MDS documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), anemia, heart failure (inability for the heart to pump blood), renal disease, thyroid disorder, arthritis and depression. A Physician order dated 1/24/2024 directed staff to complete urinary catheter management per facility guidelines and protocols every shift for urinary retention. Do not remove the catheter without a physician's order. Review…

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 review and revise the Care Plan to reflect the resident's current status for 1 of 6 residents reviewed (Resident #33). Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #33 scored 8 on the Brief Interview for Mental Status (BIMS) indicating moderate impairment. Scores range from 0 to 7 severe impairment, 8 to 12 moderate cognitive impairment, 13 to 15 no cognitive impairment. The resident had diagnoses of bilateral primary osteoarthritis of the knee and tobacco use. The assessment section entitled Functional Abilities and Goals (GG) revealed Resident #33 required partial to moderate assistance with transfers, mobility, bed mobility, dressing, and bathing. The resident utilized a walker and wheelchair. Resident #33's physician orders dated 1/19/24 stated do not remove urinary. urinary catheter to drainage. Do not remove without a physician order. urinary catheter care per 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 2 resident reviewed (Resident #14 and #20). The facility failed to obtain an INR blood test (International normalized ratio) (blood test to determine how long it takes for the blood to clot) per Physician order and failed to check/document the code alert (wander guard bracelet) per physician order. The facility also failed to administer medications per standard of practice during the medication administration task. Finding include: 1. Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #14's MDS's documented diagnoses of hypertension (high blood pressure), diabetes mellitus, cerebrovascular accident (CVA), seizure disorder, anxiety, depression, psychotic disorder and long - term use of anticoagulants (blood thinner). The MDS documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #33 scored 8 on the Brief Interview for Mental Status (BIMS), indicating moderate impairment. Resident #33 required partial to moderate assistance with transfers, mobility, bed mobility, dressing, and bathing. The resident utilized a walker and wheelchair. The MDS included diagnoses of bilateral primary osteoarthritis of the knee and tobacco use. Resident #33's physician orders dated 1/19/24 directed to not remove the urinary catheter and connect to drainage. Do not remove without a physician order. Use the urinary catheter care per facility guidelines, an 18 French (FR), 10 milliliters (mL) balloon. Resident #33's Medical Diagnoses reviewed on 2/20/24 included diagnoses created on 1/19/24 of acute kidney failure, obstructive and reflux uropathy (conditions that affect the urinary tract due to a blockage or backward flow), vesicointestinal fistula (opening between the bladder and intestine), and urinary tract infection (UTI). Resident…

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, and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 resident reviewed, requiring the use of oxygen (Resident #8). Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Resident #8's could walk independently up to 150 feet. In addition, Resident #8 could complete bed mobility, bed/chair transfers, and personal hygiene independently. Resident #8 required setup or clean - up assistance for eating, with partial/moderate assistance with upper and lower body dressing. Resident #8 used a walker. The MDS included diagnoses of asthma, chronic obstructive pulmonary disease (COPD) or chronic lung disease, idiopathic sleep related nonobstructive alveolar hypoventilation (insufficient breathing during sleep without a known cause), hypoxemia, and another…

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 observation, and staff interview, the facility failed to administer medications in a sanitary manner for 2 of 5 residents reviewed (Resident #15 and Resident #187). Findings include: On 2/21/24 at 7:17 AM witnessed Staff K, Registered Nurse (RN), administer medication to Resident #15. Staff K opened the stock bottle of Tylenol 650 milligrams (mg) and took one tablet out with their bare hands and placed the tablet in the medication cup. When Staff K administered Resident #15's medications, a tablet fell to the floor, she picked up the tablet with her bare hands. Without performing hand hygiene, she placed the tablet on the table. Staff K finished giving Resident #15 their medication, who took all of their medications with no complications. On 2/21/24 at 7:30 AM, observed Staff K apply an Exelon Patch (medication to assist memory) to Resident #15 without wearing gloves and then removed the old Exelon Patch from Resident #15 without wearing gloves. On 2/21/24 at 7:45 AM, watched Staff K administer Resident #187's medications. Staff K opened a stock bottle of Aspirin 81…

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, facility policy review and staff interview the facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff F, Cook). The facility identified a census of 39 residents. Findings include: The facility's undated and unlabeled Employee List reflected Staff F's, Certified Nurse Aide (CNA), hire date as 7/14/23. Staff F's, personal file failed to provide a Dependent Adult Abuse Mandatory Reporter Training Certification. The facility policy named Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/19/22 instructed that the facility should require staff within six months of hire to complete an initial two-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse. Interview on 2/22/24 at 10:30 AM, the Administrator said she expected the facility to follow the Abuse Policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility record review, staff interviews, and policy review, the facility failed to implement a system to consistently and accurately reconcile all controlled medications. The facility failed to count a schedule 4 controlled medication for 1 of 1 resident (#5) reviewed taking tramadol. The facility reported a census of 34 residents. Findings include: Resident #5 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #5 took opioid medications for 7 days during the look back period. The MDS included diagnoses of aftercare following joint replacement, presence of a left artificial hip and shoulder joint and osteoarthritis. A Physician Order dated 5/31/23 directed staff to administer tramadol (controlled pain medication) 50 mg (milligrams) two tablets in the morning and one tablet in the evening for pain. A facility form titled Controlled Drug Administration Record August 2023 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.

Based on staff interviews, review of facility documents and policy review, the facility failed to provide safe and secured storage of controlled substances to limit access, minimize loss and prevent diversion. The facility did not have the medication cart keys which included the key to the narcotic drawers in a secured location or in possession of an authorized person. The facility reported a census of 34 residents. Findings include: A undated facility document titled Self Report revealed on 8/26/23 at 5:50 PM during narcotic count, the facility discovered Resident #1 had 7 tablets of 60mg of Morphine missing from the narcotic drawer. On 9/6/23 at 9:40 AM, Staff D, Certified Medication Aide (CMA) reported on 8/26/23 around 12:30 PM she was asked to go to the hospital to pick up a new resident. Staff D stated she put both sets of medication cart keys which included the narcotic key in the drawer at the nurses desk. Staff D stated she returned to the facility around 1 PM and both sets of keys were sitting on top of the desk. Staff D stated she picked up the keys and put them in her…

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 staff interviews, clinic record review, and policy review, the facility failed to administer medication appropriately for 1 out of 5 residents (Resident #7) reviewed. The facility administered morphine without a physician order. The facility reported a census of 34 residents. Findings include: Resident #7 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 09, indicating moderately impaired cognition. The MDS identified Resident #7 required extensive assistance of one person with bed mobility and extensive assistance of two persons with transfers and toilet use. The MDS included diagnoses of heart failure (heart doesn ' t pump blood), hypertension, renal disease (kidney), diabetes mellitus, non-alzheimer ' s dementia and anxiety disorder. The MDS identified Resident #7 received hospice services during the look back period. The May 2023 Medication Administration Record (MAR) revealed Resident #7 was not prescribed or receiving morphine…

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.