Accura Healthcare of Marshalltown

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies for 3 of 15 areas of concern. The facility reported a census of 56 residents. Findings include: The facility QAPI Plan dated 5/23/23 documented the purpose as to identify and correct quality deficiencies as well as opportunities for improvement in the lives of nursing home residents with a systematic approach. To do this, all employees will participate in ongoing QAPI efforts which support our mission. Principals of the QAPI system included, in summary: a. The outcome of QAPI is for resident quality of care and quality of life. b. Support performance improvement by encouraging our employees to support each other and be accountable for their own professional performance and practice c. Focus on systems and processes, emphasis to identify system gaps d. Make decisions based on data includes input and experiences of others e. Identify root causes of concerns, to monitor and evaluate activities f.…

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 interviews, staff interviews and policy review, the facility failed to be respectful and ensure residents' dignity for 5 of 21 residents reviewed (Residents #9, #13, #18, #22, and #28). The facility reported a census of 56 residents. Findings include: 1. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 4/21/25 at 12:38 PM, Resident #9's reported Staff A, the previous Director of Nursing (DON), persisted and argued with her when she didn't want to take a shower. Resident #9's stated Staff A called another provider to convince her to shower and the provider didn't side with Staff A. 2. Resident #13's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. During an interview on 4/23/25 at 5:40 PM, Resident #13 recalled Staff A argued while at the nurse's station and told Resident #13 to go to their room. 3. Resident #18's…

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 Assessment, Payroll Based Journal (PBJ) data, staff and resident interviews, the facility failed to provide enough staff to care for residents in a timely manner for 5 of 17 residents reviewed (Residents #13, #30, #34, #28, and #162). The facility reported a census of 56 residents. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. On 4/21/25 at 2:45 PM, Resident #13's reported it can take staff 30 minutes up to an hour to answer her call light. She reported the second shift took the longest to answer her call lights. She added she used the clock on the wall to know the length of time. 2. Resident #30's Minimum Data Set (MDS) assessment dated [DATE] with Brief Interview for Mental Status score of 12 indicated moderate cognitive impairment. On 4/21/25 at 3:48 PM Resident #30 reported he liked to stay up late at night and some of the night staff try to get him to go to bed. 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 observations, staff interviews and policy review, the facility failed to label food and drinks with dates after opening, discard product after recommended date, ensure a male staff member wore a beard net, and failed to prepare and serve food under sanitary conditions to reduce the risk of contamination and food borne illness. The facility identified a census of 56 residents. Findings include: 1. An initial kitchen tour conducted on 4/21/25 at 9:45 AM, revealed the following items stored in the refrigerator ready for service: a. 1-quart tomato juice - open/not dated b. 1-quart silk soy milk - open/not dated c. 1-quart grape juice - open/not dated d. Container of open apricots - dated 4/13/25 e. Container of open ham salad - dated 4/13/25 f. Container of open mixed berries - dated 4/17/25 2. The kitchen's milk cooler revealed the following stored items: a. 1-gallon white milk - open/not dated b. 1-gallon chocolate mile - open/not dated c. 1-gallon orange juice - open/not dated On 4/21/25 during the initial kitchen tour, observed Staff I, Dietary Aide, with a beard and 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 facility policy review the facility failed to supervise one out of two residents reviewed for elopement (Resident #161). The facility reported a census of 56 residents. Findings Included: Resident #161's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #161 walked independently with cane. The MDS included diagnoses of Alzheimer's dementia and heart failure. The Care Plan Focus dated 3/10/25, identified Resident #161's confusion related to Alzheimer's. The Interventions directed the following: a. Directed to monitor Resident #161's behavior, redirect him as needed (PRN). b. Remind him as needed as he forgets. The Care Area Assessment (CAA) dated 3/21/25, reflected Resident #161 admitted to the facility from home as the family could no longer care for him safely due to his diagnosis of Alzheimer's Dementia. He wandered and needed supervision to keep him safe.…

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 interviews, and facility policy review the facility failed to maintain catheter tubing off the floor for 4 out of 4 days reviewed for one out of two residents reviewed (Resident #12). The facility reported a census of 56 residents. Findings include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #12 required staff assistance of 1 with toileting hygiene and 2 staff with transferring. The MDS included diagnoses of neurogenic bladder (problems with the bladder as the nerves don't function properly), and diabetes mellitus (DM). The Care Plan Focus dated 8/21/23, identified Resident #12's used an indwelling urinary catheter due to wound healing. The Goal reflected she wouldn't develop a urinary tract infection(UTI). Resident #12's Urine culture dated 3/24/25, revealed greater than (>) 100,000 colony forming unit (CFU) per milliliter (ml) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to complete a gradual dose reduction (GDR) for an antipsychotic medication for 1 out of 5 residents reviewed for unnecessary medications. (Residents #10). The facility reported a census of 56 residents. Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS identified Resident #10's as independent for bed mobility and transfers. Resident #10's MDS included diagnoses of Alzheimer's disease, non Alzheimer's disease, cerebral palsy, psychotic disorder, and other sexual disorders. The MDS documented Resident #10 took an antipsychotic during the 7-day lookback period. The Care Plan Focus revised 12/18/24 reflected Resident #10 took antipsychotic medication for Alzheimer's dementia and sexual behaviors. The Interventions directed staff to send the Pharmacist's GDR recommendations to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to provide Occupational Therapy (OT) per Physician order and failed to start Physical Therapy (PT) in a timely manner for 1 of 1 resident reviewed (Resident #1) for therapy services. The facility reported a census of 56 residents. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #13 as independent with bed mobility. Resident #13 required supervision or touching assistance from 1 staff member with transfers, toilet use, and ambulation. The MDS described Resident #13 as ambulatory and could walk 10 feet. They required a wheelchair for locomotion. Resident #13's MDS included diagnoses of hypertension (high blood pressure), COPD (chronic obstructive pulmonary disease), diabetes mellitus, and muscle weakness. An Incident Report dated 1/11/25 at 10:25 AM reflected Resident #13 fell in her room when she walked from the bathroom.…

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, the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility staff failed to follow enhanced barrier precautions (EBP) while doing wound care by not wearing the required person protective equipment for 1 of 2 residents (Resident #15) observed for wound care. The facility reported a census of 56 residents. Findings include: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #15 required substantial/maximal assistance with bed mobility. The MDS listed Resident #15 as dependent on staff for transfers. Resident #15's MDS included diagnoses of anemia (low iron levels in the blood), hypertension (high blood pressure), renal (kidney) disease, diabetes mellitus, and non Alzheimer's dementia. The MDS reflected Resident #15's had a diabetic foot ulcer. The MDS documented Resident #15 had a pressure reducing device in their…

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, Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to conduct eligibility screening, offer, and provide education related to the pneumococcal (pneumonia) immunization. In addition, the facility failed to document the vaccine consent or refusal for the pneumococcal immunization for 1 of 5 resident reviewed (Resident #47) for immunizations. The facility reported a census of 56 residents. Findings include: Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety, and hypertension (high blood pressure). The MDS listed Resident #47's pneumococcal vaccine as up to date. Resident #47's Clinical Census reviewed 4/23/25 listed an admission date of 1/18/24. Resident #47's Immunizations reviewed 4/26/25 reflected she received the pneumococcal…

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.

On 1/9/25 at 10:11 AM, witnessed Resident #2 sitting in the sun room near the nurse's station in a power wheelchair. The power wheelchair had black electrical tape on the left arm rest by the cup holder. Resident #2 acknowledged they had the black electrical tape to hold the cup holder on the arm rest. Based on observation, facility policy review, resident, and staff interview, the facility failed to keep a resident's equipment clean and in good repair for 4 of 5 residents reviewed (Residents #13, #5, #15, and #2). The facility reported a census of 61 residents. Findings include: On 1/9/25 at 11:00 AM, observed Resident #13's wheelchair with the right arm covered in torn black vinyl. The edges looked torn with exposed foam. On 1/9/25 at 11:15 AM, witnessed Resident #15's wheelchair with their right arm rest with torn vinyl and wrapped with clear plastic tape. On 1/9/25 at 11:20 AM, saw Resident #5's wheelchair with bilateral wheelchair arm rests covered with torn vinyl, exposed foam, and rough edges. On 1/12/25 at 11:00 AM, observed Resident #15's wheelchair continued to have clear…

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 document review, facility policy review, resident, and staff interview, the facility failed to provide showers per the residents' request for 4 of 4 residents (Residents #6, #1, #14, and #7) reviewed. The facility identified a census was 61 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], reflected they could understand others and they could understand them. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required substantial to maximum assistance with personal hygiene and shower/bathing. The MDS included diagnoses of anemia (low blood iron level), hypertension (high blood pressure), anxiety, depression, renal insufficiency (impaired kidney function), renal failure and Bell's Palsy (a condition that causes temporary weakness or paralysis of the muscles in the face). Interview on 1/12/25 at 12:00 PM, Resident #6 reported they only get one shower a week and would like to have a bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident, and staff interview the facility failed to provide residents with limited mobility services, equipment, and assistance to maintain or improve their mobility with the maximum practicable independence for 4 of 4 residents (Residents #13, #6, #5 and #1) reviewed. The facility identified a census of 61 residents. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #13 required substantial/maximal to total assistance with activities of daily living (ADL). The MDS included diagnoses of heart failure (impaired heart performance affecting the pumping of the heart), hypertension (high blood pressure), anxiety, depression, bipolar disorder (mood disorder) and weakness. The MDS reflected Resident #7 didn't have documentation they received a restorative nursing programs in the lookback period. The Care Plan Focus dated 5/19/22 indicated 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 2. Resident #2's MDS assessment dated [DATE] listed an admission date of 9/3/24 from home. The MDS identified a BIMS score of 14, indicating intact cognition. The MDS included diagnoses of multiple sclerosis (an autoimmune disorder that affects the nervous system and causes inflammation with damage to the protective covering of the nerves), depression, and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior) with mixed disturbance of emotions and conduct. Staff J, Director of Nursing (DON), signed the MDS indicating completion on 12/10/24. The Educational Counseling Form signed 10/7/24 by Staff J and the Administrator reflected Staff J received educational counseling related to being kind and considerate toward residents and staff members. Staff J agreed to remain professional and respectful when communicating with them. The Social Services Note dated 10/9/24 at 10:45 AM indicated on 10/8/24 at approximately 5:29 PM, the Administrator, Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to follow physician orders for 1 of 1 resident (Resident #3). The facility reported a census of 61 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 6/26/23 from a short-term general hospital. The MDS identified they had a memory problem and severely impaired cognitive skills for daily decision making. The MDS included diagnoses of unspecified severe dementia with psychotic disturbance, cerebral atherosclerosis (the hardening, thickening, and narrowing of arteries in the brain due to plaque buildup inside the artery walls), incontinence of feces (poop) and urinary incontinence. The MDS indicated Resident #3 had risk for developing pressure ulcers/injuries. Resident #3 had one or more unhealed pressure ulcers/injuries. The MDS reflected Resident #3 had a stage 2 pressure ulcer present on admission/entry. The Weekly Pressure Injury Report listed the date of onset as 11/1/24 of a Stage…

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 and staff interviews the facility failed to operate the full-body mechanical lift (lift) by allowing workers under the age of 18 to operate the lifts without adult supervision. The facility reported a census of 61. Findings Include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required substantial/maximal to total assistance with activities of daily living (ADLs). Resident #6 had a functional limitation in range of motion to upper and lower extremity on one side. The MDS included diagnoses of stroke, peripheral vascular disease (impaired blood vessels in the extremities), hemiplegia (weakness on one side of the body), and renal insufficiency (impaired kidney function). The Care plan Focus dated 10/14/20 indicated Resident #6 had an ADL deficit due to left sided hemiparesis. The Interventions directed she required assistance from 2 staff with the lift for all transfers. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to ensure staff certified in cardiopulmonary resuscitation (CPR) performed the procedure for 1 of 1 resident reviewed for initiation of CPR (Resident #2). The facility reported a census of 56 residents. Findings include: The Minimum Data Set, dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of coronary artery disease (CAD impaired blood vessels to the heart), hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat). The Care Plan Focus dated [DATE] indicated Resident #2 requested CPR. The Goal identified Resident #2's health care choice would be followed. The Iowa Physician Orders for Scope of Treatment (IPOST) signed by Resident #2 on [DATE] and the physician on [DATE] reflected Resident #2 desired CPR/Attempt Resuscitation. The Health Status Note dated [DATE] at 3:30 PM indicated the staff…

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, facility documents, and policy review, the dietary staff failed to label and store food items in order to maintain food quality and reduce the risk of contamination and food borne illness. The facility also failed to ensure resident dishes and kitchen equipment reached the appropriate sanitizing temperature when utilizing the dish machine to reduce the risk of bacteria growth and cross contamination. The facility reported a census of 53 residents. Findings include: Initial tour of the main kitchen on 7/22/24 at 10:15 AM revealed the following concerns: a. July 2024's dish machine temperature log lacked entries for seven days, two of the three required entries for four days, and one of the three required entries for one day. b. Several labels reflecting outdated food items found in the cooler: i. Squirt bottle of ranch dated 7/8/24 ii. Squirt bottle of French dated 6/30/24 iii. Bag of bacon bits dated 7/13/24 c. Four of five plastic containers of cereal didn't have a label or had an outdated label d. Plastic containers under the prep table had…

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, Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the COVID 19 (coronavirus disease) immunization for 3 of 5 resident reviewed (Resident #23, #43, #22). The facility reported a census of 53 residents. Findings include: 1. Resident #23's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the clinical record revealed Resident #23 had received a COVID vaccination on 8/11/22. The clinical record lacked documentation of education with a consent or refusal provided to Resident #23 for an additional COVID-19 vaccination after 8/11/22. Review of the CDC recommendations for adults aged 65 years and older recommended individuals to get one updated COVID 19 vaccine followed by one additional dose of an updated COVID 19…

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, observation, and staff interview, the facility failed to accurately assess residents for the need of safety smoking equipment for two of three residents reviewed for smoking (Residents #22 and #56). The facility reported a census of 53 residents. Findings include: 1. Resident #56's Minimum Data Set (MDS) assessment dated [DATE] indicated they had unclear speech and usually made themselves understood. The MDS identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #56 utilized a wheelchair. The MDS included diagnoses of tobacco use, non Alzheimer's dementia, stroke, other psychoactive substance abuse (uncomplicated), and unspecified disorder of psychological development. The Care Plan Focus dated 7/1/24 indicated that smoking is important to Resident #56. The Interventions directed the staff to assist her with proper supplies to prevent smoking related injuries. The Smoking Assessment completed 7/1/24 assessed Resident #56…

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, observation and staff interview, the facility failed to develop and implement a comprehensive person centered Care Plan for 1 of 16 residents reviewed (Residents #56), regarding the use and need of a wander guard due to history of exit seeking. The facility reported a census of 53 residents. Findings include: Resident #56's Minimum Data Set (MDS) assessment dated [DATE] indicated they had unclear speech and usually made themselves understood. The MDS identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #5 didn't exhibit wandering behaviors. Resident #56 utilized a wheelchair. The MDS included diagnoses of tobacco use, non Alzheimer's dementia, stroke, other psychoactive substance abuse (uncomplicated), and unspecified disorder of psychological development. The Care Plan with a target date of 7/7/24 lacked information related to Resident #56 wandering or the need for a wander guard. The clinical record review completed…

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 direct observation, resident interviews, staff interviews, and document review the facility failed to provide and document restorative cares for 3 of 3 residents reviewed (Residents #7, #24, and #43). The facility reported a census of 53. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #7 required full assistance for toilet use and transfers, and required maximal assistance for bed mobility. The MDS recorded Resident #7 didn't have impaired range of motion (ROM) and used a manual wheelchair for mobility. The MDS included diagnoses of congestive heart failure (CHF), respiratory failure, type 2 diabetes, and obesity. Resident #7 started Occupational Therapy (OT) on 6/14/24. Resident #7 received restorative nursing program (RNP) for 0 days in the 30-day look back period. The Care Plan Focus dated 2/12/24 reflected Resident #7 had an activities of daily living (ADL) deficit due…

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, observations, and policy review the facility failed to implement consistent supplement serving amounts for 1 of 3 residents reviewed (Resident #43) for nutrition and weight loss. The facility reported a census of 53 residents. Findings include: Resident #43's MDS assessment dated [DATE] listed an admission date of 3/9/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #43 required supervision and touch assistance with eating. In addition, Resident #43 needed extensive assistance of two staff for bed mobility and transfers. The MDS included diagnoses of anemia, hypertension (high blood pressure), heart failure (heart muscle does not pump enough blood), renal disease, diabetes mellitus, cerebrovascular accident (CVA), non Alzheimer's disease, malnutrition, dysphagia (difficulty swallowing), and anoxic brain damage (lack of oxygen to the brain). The MDS reflected Resident #43 didn't have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, the Centers for Disease Control and Prevention (CDC) and facility policy review, the facility staff failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not wearing the required personal protection equipment and rinsing resident equipment after use for one of one resident observed (Resident #52). The facility reported a census of 53 residents. Findings include: 1. Resident #52's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. Resident #52 required total staff assistance for toilet use and personal hygiene. The MDS reflected Resident #52 had a urinary catheter. The MDS included diagnoses of non Alzheimer's dementia, metabolic encephalopathy (swelling on the brain due to imbalances in the body), and urinary retention. The MDS listed active infections of septicemia (blood infection) and urinary…

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 representative interview and staff interviews the facility failed to provide notification of changes for 1 of 3 residents reviewed (#24). The facility reported a census of 52 Residents. Findings Include: The Minimum Data Set (MDS) for Resident #24 dated 8/10/23 documented diagnoses included renal failure, dependence on renal dialysis, malignant neoplasm of colon and bipolar. The MDS relayed Resident #24 has serious mental illness. The Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicated no cognitive impairment. The Electronic Profile Record updated 1/1/23 for Resident #24 revealed resident has an assigned Guardian as responsible party contact for financial and healthcare issues. The Care Plan, last review date 8/23/23 documented Resident #24 at risk for weight loss, goal to consume 50% of most meals. Staff directed to monitor weight, nutrition and hydration, to assess nutritional status and educate on diet guidelines and effects of not following the diet. The Progress Notes dated 9/29/2023 at 3:42 PM, revealed a Dietary…

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, family, and staff interviews, and facility admission Agreement review, the facility failed to ensure adequate provisions for housekeeping in a resident room (Resident #30) and failed to create homelike environment with clean carpets throughout the halls and common areas. The facility reported a census of 52 Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #30 revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition intact On 11/1/23 at 2:00 PM, Resident#30 reported their roommate went to the hospital on [DATE] and the dried urine still on the floor next to the bed. Resident #30 reported cleanliness is an issue they wanted addressed. On 11/1/23 at 4:04 PM, Resident #30 relayed his roommate had been gone since 10/29/23 and voiced had thought roommate spilled the urine container on the floor pointing to the dried, colored soiled floor. On 11/2/23 at 10:50 AM, observed the floor remained unclean with soiled…

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 review of the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 Manual, the facility failed to complete a Comprehensive Assessment after a significant change for 1 of 3 residents reviewed for Hospice (Resident #20). The facility reported a census of 52 residents. Findings Include: The Admitting Minimum Data Set (MDS) dated [DATE] documented Resident #20's diagnoses included heart failure, diabetes, osteoporosis, and osteomyelitis. A Quarterly MDS with initiation date 11/25/23 for Resident #20, documented status in progress, there was not a Significant Change Assessment to address the change to Hospice Care. The MDS tracking in the Electronic Health Record (EHR) for Resident #20 lacked a Significant Change Assessment for the Hospice admission. The Progress Note dated 10/1/23, documented a Hospice visit with resident and family, admitted resident #20 to Hospice. The Care Plan initiated 8/21/23 for Resident #20 was updated with special…

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.