Azria Health Prairie Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and the facility policy, the facility failed to keep urinary catheter tubing and collection bags off of the floor in an effort to prevent an urinary tract infection for 2 of 2 residents (Resident #3 and Resident #14) reviewed with a urinary catheter; and failed to start an antibiotic in a timely manner to treat an urinary tract infection for 1 of 2 residents (Resident #3) reviewed for urinary tract infections. The facility reported a census of 57 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident dependent with toileting hygiene and utilized a urinary catheter. The MDS revealed medical diagnoses for neurogenic bladder, type II diabetes mellitus, and a urinary tract infection (UTI) in the last 30 days. The Care Plan revealed a focus area dated 8/29/25 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.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure nursing staff locked an unattended medication treatment cart for 1 of 2 observations for medication storage. The facility reported a census of 57 residents. Findings included:Review of the Minimum Data Set (MDS) for Resident #22, dated 4/23/26, revealed a diagnosis of dementia; and Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated a moderate cognitive impairment. The resident utilized a walker to with supervision or touch assistance to ambulate. Review of the Care Plan for Resident #22, dated 2/19/26, revealed a Focus area to address elopement risk/wanderer related to the resident wandering aimlessly. On 5/12/26 at 3:18 PM, while on a walkthrough of the facility with the Maintenance Director, a 4 (four) drawer medication/treatment cart noted to be positioned across from the nurse's station by the medication room. The cart unattended by a facility staff and unlocked. Staff A, Registered Nurse (RN) at the nurse's station not watching…

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, resident and staff interview, the facility failed to serve a meal to meet the physician ordered dietary needs for 2 (Residents #9 and #16) out of 42 residents reviewed for diet orders during a breakfast service. The facility reported a census of 57.Findings included: 1. Review of the Minimum Data Set (MDS) assessment for Resident #9, dated 4/2/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Diagnoses included hip fracture, left tibia (lower leg) fracture, other fractures, and anemia (low red blood cell count).Review of the Care Plan for Resident #9, dated 4/24/26, revealed a Focus area to address I am at nutritional risk due to hospitalization.MNA (Mini Nutritional Assessment): 9/0 (4/2) At Risk for Malnutrition. Interventions initiated on 4/24/26 included:a. Diet: Consistent Carbohydrate with Double Protein portions to provide additional ~ 60 gms (grams) protein per [clinic name redacted].b. Meal Enrichments/Planned Snacks: Double protein at all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure nursing staff followed enhanced barrier precautions to prevent the spread of multi-drug resistant organisms to residents during when personal care and wound care provided for 1 of 1 resident (Resident #18) reviewed for infection control. The facility reported a census of 57.Findings included:Review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE], diagnoses listed included diabetes, incontinence without sensory awareness and morbid obesity. The assessment identified the resident had moisture associated skin damage (MASD). The MDS listed an admission date of 10/8/25. Review of electronic health record (EHR) revealed a Nurses Notes dated 10/8/25 which documented: 3 skin issues upon admit. All need the application of Triad cream (type of topical wound treatment) to areas: 1) left inner thigh shearing of skin from incontinent brief measures 2 cm (centimeters) L (length) x 1cm W…

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, and staff interviews the facility failed to ensure that residents remained free from resident to resident altercations for 1 of 9 resident records reviewed (Resident #2). The facility reported a census of 62 residents.Findings include: Review of a Facility Reported Incident, dated 12/24/25 revealed (resident name redacted, Resident #1) was sitting in front of doorway to the nurses' station when (resident name redacted, Resident #2) was trying to pass by him. As Resident #2 passed by, Resident #1 swung back hitting her in the upper back twice. This was witnessed by Restorative Aide (name redacted, Staff A) and (name redacted, Staff B, Registered Nurse (RN)). When altercation started, (name redacted, Staff A) tried to stop (name redacted, Resident #1) from hitting (name redacted, Resident #2) by holding arm, (name redacted, Resident #1) then hit (name redacted, Staff A) in the shoulder and grabbed at her abdomen pinching it and causing a bruise. Immediately separated, head to toe skin assessment and pain assessment 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 clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents are free from financial exploitation for 1 of 9 residents (Resident #3) reviewed. The facility reported a census of 62 residents.Findings include: Review of Resident #3 Minimum Data Set (MDS) assessment, dated 8/11/25 revealed a diagnoses list that included adult failure to thrive, type 2 diabetes with unspecified complications, alcoholic cirrhosis of liver without ascites (fluid accumulation in the abdomen), anxiety, and depression. The Brief Interview for Mental Status (BIMS) score of 10 out of 15 points indicated a moderate cognitive impairment. The MDS indicated Resident #3 always able to make herself understood and always understood others. The MDS identified the resident totally dependent on staff for substantial assistance to reposition in bed, transfer to and from bed or chair, and unable to stand or ambulate. Review of a Facility Self-Reported Incident, dated 12/7/25, revealed When…

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, resident and family interviews, the facility failed to make an attempt to meet resident needs prior to issuing emergency discharges for 2 of 2 residents (Resident #1 and Resident #5) reviewed. After a resident to resident altercation the facility issued emergency discharges to Resident #1 and Resident #5 upon their transfer to the hospital for an evaluation. The facility reported census was 57.Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of July 17, 2025, Resident #1 had a Brief Mental Status (BIMS) score of 14 of 15, indicating an intact cognitive status. Resident #1 was coded independent to needing supervision assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included coronary artery disease, atrial fibrillation and was always continent of bladder and bowel.According to the facilities Notice of Resident Transfer or Discharge form dated Sept. 16, 2025, directed to Resident #1'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.

Based on observation, facility policy review, and staff interviews, the facility failed to store, prepare and handle food in a sanitary manner in an effort to prevent cross contamination and food borne illness during 2 of 2 kitchen observations. The facility reported a census of 53 residents. Findings include: During the initial tour of the kitchen on 7/28/25 at 1:15 PM, a metal basin observed to contain raw hamburger thawed on an upper shelf of rack. Meal trays with lidded plates rested on the shelf underneath. During an observation on 7/30/25 at 10:03 AM, bags of frozen chicken breasts in a stainless steel basin were placed on the second shelf of the refrigerator. Fruits in the plastic containers with plastic lids sat under the meat on the bottom shelf. Staff N, [NAME] noticed the meat on the second shelf and moved it to the bottom shelf. During an interview on 7/30/25 at 10:04 AM, Staff N, [NAME] stated she kept telling staff to put the meat on the bottom shelf so it didn't drip everywhere. During a continuous observation during the lunch meal service on 7/30/25 at 12:06 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and residents interviews, record review, and the facility policy, the facility failed to treat residents in a dignified manner for 3 of 3 residents (Resident #11, Resident #21, and Resident #33) reviewed for dignity. The facility reported a census of 53 residents, Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS indicated the resident required supervision or touching assistance with eating. The MDS revealed medical diagnoses for stroke, aphasia following cerebral infarction. The Care Plan revealed a focus area revised on 6/25/25 for difficulty swallowing and pocketing food status post cerebral vascular accident. The intervention revised on 7/16/25 indicated distant supervision; Resident #11 will pocket solids and liquids, he is able to clear when allowed. Please do not instruct Resident #11 to swallow or prevent him from taking…

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, record review, and the facility policy, the facility failed to notify the physician of a resident's weight loss for two different occurrences for 1 of 3 residents reviewed for nutrition (Resident #7). The facility reported a census of 53 residents. Findings Include: The MDS assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed a loss of 5% or more in the last month or loss of 10% or more in 6 months and on a therapeutic diet. The MDS revealed resident took an diuretic. The Care Plan revealed a Focus area revised on 8/6/25 for I am at nutritional risk s/p (status post) acute on chronic CHF (Congestive Heart Failure) with h/o (history) Type 2 DM (diabetes mellitus), COPD (Chronic Obstructive Pulmonary Disease), morbid obesity, gout, hypothyroidism, hyperlipidemia, pneumonia.8/1/25- significant weight loss over 6 months. The Interventions dated 1/2/24 revealed meal enrichment/planned snacks: at least 1 cup…

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 update Care Plans to reflect two residents had a significant weight loss and one resident no longer received dialysis services for 3 of 18 (Resident #7, Resident #11 and Resident #3) reviewed for Care Plans. The facility reported a census of 53 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed a loss of 5% or more in the last month or loss of 10% or more in 6 months and on a therapeutic diet. The MDS indicated Resident #7 took a diuretic (often called a water pill, a medication to help the body eliminate excess salt and water). Review of the Care Plan revealed a Focus area revised on 8/6/25 for I am at nutritional risk s/p (status post) acute on chronic CHF (Congestive Heart Failure) with h/o (history) Type 2 DM (diabetes mellitus), COPD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, and resident and staff interviews, the facility failed to follow speech therapy recommendations for eating assistance for 1 of 18 residents reviewed for following provider orders (Resident #11). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS indicated the resident required supervision or touching assistance with eating. The MDS revealed medical diagnoses for stroke, aphasia following cerebral infarction. The MDS indicated resident not had a weight loss of 5% in one month or 10% in 6 months and not on a therapeutic diet. Review of the Care Plan revealed a Focus area revised on 6/25/25 for difficulty swallowing and pocketing food status post cerebral vascular accident. The Intervention revised on 7/16/25 indicated distant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, and resident and staff interviews, the facility failed to provide an intervention in a timely manner for a resident who complained of a rash and associated discomfort for 1 of 18 residents (Resident #21) reviewed for assessment and intervention. The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 scored a 15 out of 15 on the Brief Interview for Mental Status exam, which indicated cognition intact. The MDS indicated resident required partial/moderate assistance with upper body dressing; and substantial/maximal assistance with shower/bathing self. Review of the Care Plan revealed a Focus area revised on 7/29/25 for increased risk for impairment of skin integrity and potential pressure ulcer development related to fragile skin, history of pressure wounds and mobility impairment.The interventions dated 7/21/25 revealed avoid scratching and keep hands and body…

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 implement a restorative nursing program per guidance from therapy for 1 of 1 resident (Resident #25) reviewed for positioning and mobility. The facility reported a census of 53 residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident had no impairment to upper extremities, and had impairment to one side of lower extremities. During an interview on 7/29/25 at 9:33 AM, Resident #25 stated she had done restorative exercises one time. Review of the Care Plan last revised 7/18/25 revealed a Focus area to address Restorative Programming required to maintain current level of functional mobility (Ax2 with walker and gait belt for stand pivot transfers), to preserve joint integrity, preserve strength/ROM, and to prevent decline…

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, and record review the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from twenty-seven opportunities for 3 of 6 residents reviewed for medication administration (Resident #28, Resident #33, Resident #36). This deficient practice resulted in facility medication error rate of 11.11%. The facility reported a census of 53 residents. Findings include: 1.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took insulin for four of the last seven days. The Physician Order dated 7/1/25 revealed, Insulin Lispro Inject as per sliding scale: if 0 - 60 = 0 Units Follow Hypoglycemia Protocol; 61 - 140 = 0 Units; 141 - 180 = 1 Unit; 181 - 240 = 2 Units; 241 - 300 = 3 Units; 301 - 350 = 4 Units; 351 - 400 = 5 Units; 401+ = 0 Units Notify Physician for…

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, and record review the facility failed to ensure Warfarin and Apixaban, anticoagulant medications, sliding scale insulin, and narcotic pain medication were administered per physician order for four of four residents reviewed for significant medication errors (Resident #20, Resident #36, Resident #55 and #62). The facility reported a census of 53 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took anticoagulant medication. Review of Resident #20's Physician Order dated 6/13/25, discontinued on 6/17/25, revealed the following: Warfarin, also known as Coumadin) Sodium Oral Tablet 4 mg (milligram) with directions to give 1 tablet by mouth one time a day every Monday, Tuesday, Wednesday, Friday, and Saturday for anticoagulant therapy. Review of the resident's Medication Error Form…

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 ensure quarterly Minimum Data Set (MDS) assessments completed timely for 5 of 19 residents reviewed for completion of comprehensive assessments (Resident #9, Resident #18, Resident #26, Resident #29, and Resident #34). The facility reported a census of 55 residents. Findings include: 1. The Quarterly MDS assessment for Resident #18 revealed an assessment reference date (ARD) of 4/25/24. The resident's MDS assessment completion date documented 5/20/24. 2. The Quarterly MDS assessment for Resident #26 revealed an ARD of 8/9/24. The resident's MDS assessment was still in process. 3. The Quarterly MDS assessment for Resident #29 revealed an ARD of 7/11/24. The resident's MDS assessment completion date documented 8/8/24. 4. The Quarterly MDS assessment for Resident #34 revealed an ARD of 4/18/24. The resident's MDS assessment completion date documented 5/20/24. The Quarterly MDS assessment for Resident #34 revealed an ARD dated of 7/18/24. The resident's MDS assessment completion date documented 8/13/24. 5. 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 interviews, and facility policy review the facility failed to ensure annual Minimum Data Set (MDS) assessments completed timely for 2 of 19 residents reviewed for completion of comprehensive assessments (Resident #18, Resident #26). The facility reported a census of 55 residents. Findings include: 1. The Annual MDS assessment for Resident #18 revealed an assessment reference date (ARD) of 7/25/24. The resident's MDS assessment was currently still in process. 2. The Annual MDS assessment for Resident #26 revealed an ARD of 5/9/24. The resident's MDS assessment completion date documented 6/3/24. During an interview on 8/29/24 at 11:03 AM, Staff A, MDS Coordinator confirmed the MDS for Resident #18 and #26 were late and they needed to be completed within 14 days of the ARD date. During an interview on 8/29/24 at 12:38 PM, the DON (Director of Nursing) stated he expected the MDS to be completed on time. During an interview on 8/29/24 at 12:56 PM, the Administrator stated she expected the MDS be completed by the date they were due. The Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, staff interviews, and the facility policy review, the facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) with new mental health diagnoses and psychotropic medications added to the plan of care for 1 of 2 residents reviewed for PASRR (Resident #20). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnoses for anxiety disorder, depression, and psychotic disorder (other than schizophrenia). The MDS revealed the resident took an antipsychotic and an antidepressants. The MDS revealed the resident took antipsychotics on a routine basis. The Notice of PASRR Level 1 Screen Outcome dated 5/24/17 revealed no Level II required unless a significant change. The PASRR revealed the diagnoses of unspecified psychiatric illness and no medications…

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 administer a pneumococcal vaccine to 1 of 5 residents reviewed for pneumococcal vaccines (Resident #8). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The EMR (Electronic Medical Record) revealed the resident received the Prevnar 13 vaccination on 5/16/19. The resident's file revealed a screen shot of immunization that the ARNP (Advanced Registered Nurse Practitioner) reviewed the immunizations and noted resident received PCV 13 in 2019 and eligible for the PCV 20 dated 2/13/24. The Progress Notes dated 2/14/24 at 12:44 PM, revealed the Immunization Record sent to PCP (primary care provider) for review and returned that the resident was able to have the PCV20 (pneumococcal 20-valent conjugate) vaccine at this time…

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, the facility failed to maintain a clean environment free of hazards. Observations found resident rooms poorly cleaned, leaving debris and trash under beds for multiple days and hallways cluttered with equipment and wheelchairs. Findings include: During an observation on 6/4/24 at 4:30 p.m. debris (rubber glove) and trash were noticed under resident bed A in room [ROOM NUMBER] and a glove on the bathroom floor. During an observation on 6/5/24 at 11:00 a.m. and again at 2:50 p.m. the trash and glove remained under resident bed A in room [ROOM NUMBER], after housekeeping had been in the room to clean it that day. During an observation on 6/6/24 at 9:00 a.m. the glove and trash remained on the floor under the bed of room [ROOM NUMBER]. During an observation on 6/6/24 at 9:00 a.m. a gown and a deodorant container found on the floor in room [ROOM NUMBER]. Later that morning the gown was picked up, but the deodorant container remained on the floor behind 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, infection control policy, clinical record review and staff interview, the facility failed to use enhanced barrier precautions and consistent hand hygiene practices between resident contact. The facility reported census was 48. Findings include: According to the Mnimum Data Set (MDS) assessment, dated 2/26/24, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required moderate assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnoses included congestive heart failure, atrial fibrillation, coronary artery disease, diabetes mellitus, renal insufficiency, arthritis. Resident #6 has a catheter and is on enhanced barrier precautions. During an observation on 6/6/24 at 7:30 a.m. Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA assisted Resident #6 with personal care. Neither Staff E or Staff F wore a protective gown. In an interview on 6/6/24 at 7:35 a.m. Staff E, Certified Nurse Aide,…

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

Based on record review, staff interviews, and the facility policy the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in a timely manner for 4 of 15 residents reviewed for quarterly MDS assessments (Resident #4, #22, #35, #46). The facility reported a census of 48. Findings include: 1. Resident #35 MDS quarterly assessment ARD (Assessment Reference Date)/Target Date dated 4/20/23 completed on 5/22/23 and accepted/locked on 4/11/23. 2. Resident #22 MDS quarterly assessment ARD/Target Date dated 7/1/23 and not completed until 7/16/23 and accepted/locked on 7/17/23. 3. Resident #46 MDS quarterly assessment ARD/Target Date dated 10/15/23 and not completed until 11/16/23 and accepted/locked on 11/16/23. During an interview on 11/30/23 at 12:05 PM, Staff L, MDS coordinator queried on who did the MDS assessments and she stated she did. Staff L informed the resident whose quarterly MDS assessments not completed timely and she stated she couldn't make excuses, it was black and white. She stated the old Director of Nursing (DON) left in the middle of September and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bed rails, use of foot pedals during transport, and documentation of behaviors, anxiety, and major depressive disorder were addressed on the Care Plan for four of fifteen residents reviewed for Care Plans (Resident #7, Resident #11, Resident #22, Resident #30). The facility reported a census of 48 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 11/9/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. Per the assessment, a bed rail was not used in bed for the resident. The Care Plan did not address use of bed rails for the resident. The Physician Order dated 6/11/21 documented, Halo/grab barsx2 for bed mobility and positioning. No directions specified for order. On 11/29/23 at 8:35 AM, observation of Resident #11 revealed the resident in her wheelchair in her room. Resident #11's bed observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to serve food that was warm and palatable for three of twenty four residents reviewed (Resident #23, Resident #30, Resident #103). The facility reported a census of 48 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #30 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency (Kidney Failure) and Diabetes Mellitus. The MDS also identified Resident #30 required substantial staff assistance with lower body dressing, putting on footwear. In an interview on 11/29/23 at 8:30 AM sitting up in wheelchair in her room, Resident #30 complained that the food is horrible. The pasta is always overcooked and food has no taste. Breakfast is always cold, especially the eggs. She reported she had spoken to many people about it, even the dietitian. On 8/31/20, the care plan identified Resident #30 with the problem…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, clinical record review, the facility failed to ensure the dignity of two of three reviewed (Residents #3 and #7). The facility reported a census of 47 residents. Findings included: 1. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 13. The MDS documented the resident had the following diagnoses; Atrial Fibrillation (an abnormal heart rhythm), Pneumonia and Arthritis. The MDS also identified Resident #3 required substantial assistance with oral hygiene, upper body dressing and totally dependent on staff for toileting, showering, lower body dressing, putting on foot wear and repositioning. The MDS also documented that Resident #3 had an indwelling catheter. Observations of Resident #3 revealed the urinary drainage bag was not placed in a dignity bag on 11/27/23 at the following times: At 10:35 AM observed the resident as follows; she sat up in her wheelchair 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 observation, interviews, record review, and the facility policy, the facility failed to have the call light within reach for a resident while in bed for 1 of 1 residents reviewed for call lights (Resident #35). The facility reported a census of 48. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 scored a 11 out of 15 on the Brief Interview Mental Status (BIMS) which indicated moderately impaired cognition. The MDS documented impairment on both sides of his lower extremities and the resident used a wheelchair. The MDS documented the medical diagnosis of Parkinsons, unspecified. The Care Plan revealed a focus area dated 11/18/21 of increased risk for actual/potential limitations in my ability to perform my ADL (Activities of Daily Living) related to generalized weakness and cognitive deficits. The interventions dated 1/24/22 directed staff to encourage the resident to use the bell to call for assistance. The Care Plan revealed a focus area initiated 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 00. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet. Observations of the resident during the survey from 11/27/23 through 11/30/23 revealed the resident's bed with two ¼ side rails up. In an interview on 11/29/23 at 10:19 AM, Resident #7 reported she purchased her own bed as it had an air mattress and the side rails came with it, but none of the staff had provided any kind of education on safety issues on it. In an interview on 11/29/23 at 10:45 AM, the Director of Nursing reviewed the resident's Electronic Medical Record and verified there was no documentation of side rail evaluation,…

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, and facility policy the facility failed to document the resident's Advance Directives for two of two residents reviewed (Residents #103 and #203). The facility reported a census of 48 residents. Findings included: 1. At the time of the survey, the admission MDS for Resident #103 had not been completed. A review of the Electronic Medical Record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side. The admission Progress Note dated [DATE] at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place. The admission Progress Note documented the resident had diagnoses which included weakness with falls, and would be on skilled level of care for therapy after discharge from a hospital. On [DATE], a review of the EMR revealed no documentation to address Resident #103's preference for Advance Directives (legal documents that provide instructions for medical care and…

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

Based on observation, interview, and record review, the facility failed to ensure physician notification occurred for heart rate per parameters included the resident's Care Plan for one of one residents reviewed for physician notification (Resident #4). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 10/5/23 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan dated 7/14/21 documented, The resident is on Digoxin Therapy r/t (related to) atrial fibrillation. The Intervention dated 7/14/21 documented, Report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. Review of documentation of the resident's pulse for October 2023 and November 2023 revealed the following dates, times, and documentation of heart rate less than 60. Documentation of the resident's heart rate on 10/1/23 and 10/2/23 revealed the following instances of heart rate less than 60: a. 10/1/23…

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 provide a homelike environment by cleaning and removing stains and dried food on a resident's recliner for 1 of 2 residents reviewed for cleanliness of the building (Resident #22). The facility reported a census of 48. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status which indicated cognition intact. The MDS revealed medical diagnoses of stroke and hemiplegia following cerebral infarction affecting the right dominant side. During an observation on 11/27/23 at 10:58 AM, Resident #22 right side seat cushion on the recliner dirty with dried food and stains on it. Incontinent pad on the recliner had a brown mark smeared on the end of it by the stains on the seat. During an interview on 11/27/23 at 10:58 AM, Resident #22 stated the staff spend about 10 minutes in his room to clean. He stated he ate in his chair…

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, interviews, record review, and the facility policy review, the facility failed to ensure residents free from chemical restraints when narcotics pain medication was administered for management of resident's behavior for 1 of 5 residents reviewed for unnecessary medications (Resident #15). The facility reported a census of 48. Findings include: The MDS Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 scored a 2 out of 15 Brief Interview of Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS documented the resident was unable to answer presence of pain. The MDS indicated the resident received scheduled pain medications, and the resident received or was offered As Needed (PRN) pain medications, and the resident didn't receive non-medication intervention for pain. The MDS documented that the resident received antipsychotics, antidepressants, anti-anxiety, and an opioid class of medications that are considered high-risk drug classes. 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 record review, interviews, and the facility policy review, the facility failed to provide the required documentation needed for transfers to the hospital for 1 of 3 residents reviewed for hospitalizations (Resident #22). The facility reported a census of 48. Findings include: The MDS Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMs) exam, which indicated cognition intact. The MDS revealed medical diagnosis for anxiety disorder and depression. The Social Work Progress Note dated 4/3/23 at 1:21 PM revealed the staff reported Resident #22 make gestures with a gait belt, gestures of wrapping it around his neck and hanging himself. The Director of Nursing (DON) (put one on one in place immediately. Social Services had a conversation with Resident #22 about his gesture of hanging himself and he denied it. However with further conversation he stated that he cried all of the time and felt sad all the time. Social Services…

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 consistently notify the ombudsman of a resident's transfer to the hospital for 1 of 3 residents reviewed for hospitalization (Resident #22). The facility reported a census of 48. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed medical diagnosis for anxiety disorder and depression. The Progress Note dated 10/8/23 at 2:30 PM, revealed at 2:15 PM reported resident found on the floor. On assessment resident complained of pain in lower back and tailbone area. When trying to get vitals and check Range of Motion (ROM) resident became combative with a history of doing so. Resident kicking walker and and hit staff. Let him know if he would not let us assess him, the hospital needed to check him out. Resident started hitting again. Called on call doctor. New order to send…

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

Based on record review, staff interviews, and the facility policy the facility failed to complete the Annual Minimum Data Set (MDS) assessment within a timely manner for 3 of 15 residents reviewed for annual MDS assessments (Resident #15, #22, #35). The facility reported a census of 48. Findings include: Resident #35 MDS Annual assessment Assessment Reference Date (ARD)/Target Date dated 10/12/23 completed on 11/8/23 and accepted/locked on 5/22/23. Resident #22 MDS Annual assessment ARD/Target Date dated 9/21/23 and not completed until 10/17/23 and accepted/locked on 10/17/23. Resident #15 MDS Annual assessment ARD/Target Date dated 8/17/23 and not completed until 9/12/23 and accepted/locked on 9/12/23. During an interview on 11/30/23 at 12:05 PM, Staff L, MDS Coordinator queried on who did the MDS assessments and she stated she did. Staff L informed the resident whose annual MDS assessments not completed timely and she stated she couldn't make excuses, it was black and white. She stated the old Director of Nursing (DON) left in the middle of September and she was pulled to 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 observation, interview, and record review the facility failed to ensure timely completion of a Significant change Minimum Data Set (MDS) assessment for one of one resident reviewed for significant change assessments (Resident #14). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14 revealed the assessment reference date 8/25/23. The completion date for the assessment revealed 9/20/23. The Care Plan dated 10/13/23 documented, I am receiving Hospice Services through [Redacted] due to end stage dementia, Parkinson's disease, Chronic Obstructive Pulmonary Disease (COPD), and dysphagia. On 11/30/23 at 12:04 PM when queried as to the timeframe to complete significant change assessments, the Minimum Data Set (MDS) Coordinator acknowledged 14 days from the date a significant change determined. The MDS Coordinator acknowledged she was behind, and was pulled to work the floor. The Facility Policy titled [Facility] Resident Assessments dated March 2022 documented, OBRA-Required Assessments - are federally mandated,…

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, clincial record review, and facility policy review the facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessment to address use of bed rails, gastrostomy tube, and weight loss for two of fifteen residents reviewed for MDS accuracy (Resident #7, Resident #11). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. Per the assessment, Resident #11 did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Per the assessment, a bed rail was not used in bed. The Dietary Progress Note dated 11/2/23 at 7:51 PM documented, WT (weight) - 97#(11/2)[BMI (body mass index)= 20.3 .RD (Registered Dietician) notes significant weight loss (-)10.2% X 3 mos using wt of 108#(8/01) as comparison weight. On 11/29/23 at 8:35 AM,…

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

Based on observation, record review and staff interview, the facility failed to address the problem of an open wound on the initial care plan for one of one residents admitted within the last 30 days. (Resident #103). The facility reported a census of 48 residents. Findings included: 1. At the time of the survey, the admission Minimum Data Set (MDS) had not been completed for Resident #103. A review of the Electronic Medical Record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side. In an observation and interview with the resident on 11/27/23 at 10:03 AM, the resident sat up in the recliner in his room with feet elevated, he reported he came in with an open area to the left shin which had kerlix dressing dated 11/25/23. He wore tubigrips to both legs which had with 2 pluse edema (swelling of tissue). A review of the Progress Note dated 11/22/23 at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place. On 11/27/23, a review of the EMR revealed the only problem…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, the facility failed to update the Care Plans for two of fifteen residents reviewed after returning from the hospital (Residents #7 and #22). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a Brief Interview for Mental Status score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet. A review of the progress notes revealed the following: a. 7/22/23 at 1:50 AM Resident #7 complained of pain in her right upper quadrant rating it a 9 and states it feels like someone is punching her there. Also states she has been having this pain intermittently for about a week now. Bowels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to follow physician orders and administer blood pressure medications per accepted standard of practice for 3 of 15 residents reviewed (Residents #7, #11, and #30) The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet. A review of the physician orders revealed the following: a. 5/12/23 G-Tube is to be clamped during meals and Med Pass and for 30 minutes after otherwise to vent at all times every shift for Gastric Outlet Obstruction. b. 5/17/23 Drain…

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, and record review the facility failed to ensure through assessment prior to a resident's hospitalization, failed to ensure throrough assessment post a documented episode of choking, and failed to ensure the dressing to a non-pressure skin wound changed as ordered for three of four residents reviewed for assessment/intervention (Resident #7, Resident #14, Resident #103). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #14 dated 8/25/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. The Health Status Note dated 10/17/23 at 8:59 AM documented, Resident AM BG (blood glucose) very low (57). He was assisted OOB (out of bed) and into dining room and given honey thickened chocolate milk and orange juice. Recheck 1 hour later was 135. While eating breakfast, resident choked on biscuits and gravy. Resident cyanotic but coughing.…

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 and record review, the facility failed to ensure a resident was able to access appropriate and timely vision care by an outside provider. The resident's vision had declined over the last nine months. (Resident #23) The facility reported a census of 48 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident # 23 dated 10/05/23 documented the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated the resident was cognitively intact. Care Plan for Resident #23 dated 04/06/2020 and revised on 07/19/2020 with a Target date of 01/10/2024 documented the following focus area, goals and interventions: Focus area: My visual ability needs and preferences are: I wear eyeglasses. Date Initiated: 04/06/2020 Revision on: 04/06/2020 Goal: I will use appropriate visual devices to promote participation in ADLs and other activities. Date Initiated: 4/06/2020 Revision on: 07/19/2022 Target Date: 01/10/2024 Interventions: a. I…

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, and record review, the facility failed to thoroughly investigate falls, determine root cause analysis, and ensure pre-existing interventions were implemented for fall prevention, and failed to ensure foot pedals utilized when a resident pushed in their wheelchair for two of five residents reviewed for accidents (Resident #11, Resident #30). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #11 dated 8/19/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per the assessment, Resident #11 did not have any falls since admission, entry, reentry, or the prior assessment. The Care Plan dated 7/8/21, revised 7/13/21, documented, the resident is at risk for falls related to generalized weakness, impaired cognition, and impulsivity. The Intervention dated 3/2/23 documented, Resident to have gripper socks on at bedtime. 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 observation, interview, and record review, the facility failed to ensure consistent completion of assessments prior to dialysis for one of one resident reviewed for dialysis (Resident #37). The facility reported a census of 48 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #37 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per the assessment, the resident received dialysis while a resident. The Care Plan dated 8/3/22 documented, I have alteration of my renal function and require DIALYSIS d/t (due to) End Stage Renal Disease. I refuse to be weighed at the facility. The Intervention dated 8/3/22 documented, The facility will assist me, as needed, to coordinate services and care with my dialysis clinic. Communication with the dialysis center will be done pre/post each visit using a communication sheet or via phone and documented. Review of the resident's COMS-Pre/Post Dialysis Evaluation revealed only one evaluation had been completed for the resident 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, interview, and record review, the facility failed to ensure informed consent completed for use of side rails and ensure assessments completed for use of side rails for two of two residents reviewed for side rails (Resident #7, Resident #11). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #11 dated 11/9/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. Per the assessment, a bed rail was not used in bed for the resident. The Care Plan did not address use of bed rails for the resident. The Physician Order dated 6/11/21 documented, Halo/grab barsx2 for bed mobility and positioning. No directions specified for order. On 11/29/23 at 8:35 AM, observation of Resident #11 revealed the resident in her wheelchair in her room. Resident #11's bed observed to have partial rails bilaterally on the resident's bed, with one rail up and one rail…

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, and record review the facility failed to accurately document receipt of hospice services and completion of a wound treatment for two of two residents reviewed for records (Resident #18, Resident #103). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #18 dated 9/16/23, completed 9/22/23, revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam. Per the assessment, Resident #18 did not receive hospice care while a resident. The Care Plan revised 11/16/23 documented, I am at nutritional risk due to h/o (history of) ETOH (alcohol) dependence, cardiomyopathy, cirrhosis and weight loss hx (history). I have been admitted to Hospice in October 2022 and Decertified in [DATE]. Resident to be certified for Hospice Care end of June/Early July 2023. As of October 2023 resident remains decertified from Hospice. The Health Status Note dated 9/18/23 at 8:22 AM documented, Resident discharged from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to ensure proper infection control techniques for one of three residents observed during medication pass (Resident #6), during the drainage of a GT (gastric tube) drainage bag for one of one residents observed with a GT drainage bag (Resident #7) and during wound care for one of one residents observed (Resident #103). The facility reported a census of 48 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #6 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease, Parkinson's Disease and Anxiety Disorder. The MDS also identified Resident #6 as independent with most activities of daily living. During observation of med pass for Resident #6 on 11/28/23 at 6:35 AM, Staff B, RN removed one tablet of Alprazolam 1 mg from blisterpack, the pill fell out on top 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 Immunization Registry Information System (IRIS) review, staff interview, and facility policy review, the facility failed to ensure pneumococcal vaccines offered timely for two of five residents reviewed for immunizations (Resident #4, Resident #11). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 10/5/23 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of Resident #4's electronic health record revealed the resident was born in 1932. Review of IRIS documentation for the resident revealed the resident received PCV-13 (Pnuemococcal Polysacharide) on 11/17/16. IRIS documentation of immunizations lacked additional pneumococcal vaccination administration. Review of a paper Vaccination History document provided by the facility revealed the resident last had PPSV-23 (Pneumococcal Polysaccharide) on 10/24/02. The webpage…

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 Information Registry Information System (IRIS) review, staff interview, and facility policy review, the facility failed to ensure a resident was offered COVID-19 vaccination(s) timely for one of five residents reviewed for immunizations (Resident #18). The facility reported a census of 48 residents. Findings include: Review of census information for Resident #18 revealed the resident admitted to the facility 8/17/22. Review of IRIS documentation for the resident revealed the resident received one dose of a two dose series for COVID-19 vaccination on 8/17/22. The resident had another COVID-19 vaccine which could be given 9/7/22 per the earliest date per IRIS, 9/7/22 per the recommended IRIS information, and considered past due 9/28/22 per IRIS. Review of the resident's Vaccination History per a paper form provided by the facility revealed dose 1 of a 2 dose series given 8/17/22. Review of the Immunization Consent/Declination Form revealed consent for COVID-19 dated 11/15/23. On 12/4/23 at 4:38 PM, the Administrator explained via email the facility did not have further…

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.