Accura Healthcare of Newton East, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, staff, and resident interviews, the facility failed to report an allegation of missing money for 1 of 3 residents reviewed (Resident #6) for abuse. The facility reported a census of 54 residents.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. The MDS included diagnoses of anxiety disorder, depression, and schizophrenia.On 8/5/25 at 11:54 AM, Resident #6 stated she had $10 missing her friend gave her on 8/4/25. She stated she informed the Administrator that she had missing money. She added she felt one of the Certified Nursing Assistants (CNAs) took it. Resident #6 reported this concern to the State Agency again on the morning of 8/6/25.On 8/5/25 at 4:02 PM, the Administrator stated Resident #6 reported the missing money to her the day before. She stated Resident #6 changed her story many times and no staff witnessed the friend visit. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, the facility failed to ensure residents received showers and/or baths at least once a week for 1 of 3 residents reviewed for bathing (Resident #5). The facility reported a census of 54 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of hemiplegia (weakness or paralysis on one side of the body), heart failure, and depression. The MDS listed Resident #5 as independent with bathing. The Care Plan Focus initiated 3/25/24 indicated Resident #5 had an activities of daily living (ADLs) deficit related to a cerebral vascular accident (stroke). The Intervention initiated 6/30/24 directed Resident #5 required assistance from 1 staff for bathing. During an interview on 8/4/25 at 1:44 PM, Resident #5 reported she went 3 weeks at times without a shower. Resident #5 said the staff always…

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

Based on staff interviews, employee job description and policy , the facility failed to ensure adequate, trained, dietary staff for a clean kitchen environment. The dietary manager did not meet the regulated educational qualifications, the kitchen lacked appropriate sanitary conditions (photos available). The facility reported a census of 48 residents. Findings include: During an interview on 2/10/25 at 9:25 AM Staff B, Kitchen Manager reported working at the facility only a few months, beginning, December 2024. Staff B relayed the previous kitchen manager left and had recommended Staff A, laundry/housekeeper for promotion to kitchen manager. Staff B reported dietary training in several fast food environments, which included a course in food safety for managers and had not yet completed the Certification for Dietary Manager (CDM) coursework. On 2/10/25 at 9:30 AM Staff B, Kitchen Manager (KM) reported each shift is supposed to clean the kitchen at the end of the shift and it is apparent that had not occurred over the weekend. Staff B, KM acknowledged the dirty floors, equipment 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 observations, resident and staff interviews, the facility failed to provide food that was palatable and at an appetizing temperature for 5 out of 5 residents reviewed (Res #8, #13, #17, #35, & #43). The facility reported a census of 48 residents. Finds include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] Resident #13 revealed the Brief Interview for Mental Status (BIMS) was 15 which indicated an intact cognition. During an interview on 2/10/25 at 12:07 PM Resident #13 stated that the lunch food that was to be served at noon came at 1:30 PM and her lettuce in the chef salad was wilted. Resident #13 stated the breakfast food was cold all of the time. 2. The MDS dated [DATE] Resident #17 revealed the BIMS was 15 which suggested an intact cognition. During an interview on 2/10/25 at 10:29 AM Resident #17 was in a wheelchair in her room with a meal tray covered with plastic on her bedside table untouched. She stated it was cold. 3. The MDS dated [DATE] Resident #35 revealed the BIMS was 15 which…

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

Based on observations, food provider documents and staff interviews, the facility failed to prepare food to meet the needs for 8 of 8 residents who required the meal to be mechanical soft (Residents #27, #32, #11, #26, #15, #9, #2, #29). The facility reported a census of 48 residents. Findings include: During an observation on 2/13/25 at 12:14 PM, Staff B, Dietary Manager prepared mechanical soft meat by placing 6 chicken pieces into the food processor then put the prepared meat into a metal pan on the steam table. Further observation revealed Staff N, [NAME] utilized a scoop and shook the prepared chicken in attempt to level it and meat fell out, less than a scoop, placed it on a plate and another plate was served with a scoop full. Staff B made a plate with mechanical soft chicken and put 2 scoops on one plate and another with a little more than a scoop full. During an interview on 2/13/25 at 1:48 PM, Staff N, [NAME] stated he did not know what size of scoop he was using to serve. Staff N stated he was new to cooking in a facility as he was working in a fast food restaurant prior…

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

Based on observation, staff interview, and policy review, the facility failed to maintain a clean sanitary environment in the kitchen and failed to store food in accordance with professional standards for food service safety included food not covered. The facility reported a census of 48. Findings include: On 2/10/25 at 9:25 AM observations during initial tour of the facility kitchen revealed the following; a. the floor tiles under the sink missing with gray/ black residue on flooring b. grime and water stains evident under the sinks c. refrigerator handle and interior tray with food crumbs present d. front of the stove revealed dripping residue and traces of food e. the stainless appliances were not clean f. sand like debris on top of the dishwasher g. various items on the floor included silverware, cup, papers, food crumbs and spills h. bowls of cereal uncovered and a tub of peanut butter half empty covered loosely with a piece of plastic g. sticky pest traps in most corners (photos available). On 2/10/25 at 9:30 AM Staff B, Kitchen Manager (KM) reported each shift is supposed 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.

Based on observation, staff interview and facility assessment review the facility failed to maintain essential equipment available to be used in safe operating conditions. A washing machine noted out of order, debris behind the washers related to water backing up, a dryer did not automatically cool down or shut off. The facility had reported a census of 48. Findings include: 1. On 2/10/25 at 10:06 AM initial laundry tour observed two large industrial size washers, one with a sign on the front documented out of order, behind the washer were water stains on the piping and grayish dirty debris on the floor and the pipes. Observed two industrial size dryers, one had a sign taped that read, Keep eye on dryer, wont shut off by its self (photos available). On 2/10/25 at 10:10 AM Staff A, Laundry/Housekeeper (LH) explained only one of the large washers is working. Queried Staff A regarding the debris behind the washer, Staff A responded the pipes can back up from grease or oils and had pillow stuffing shoot out back of the washer as well. Staff A relayed the sign on the dryer reflected 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 observations, staff interviews and commercial pest control documents, the facility failed to maintain an effective pest control program so that the facility would be free of pests. The facility also failed to follow through with recommendations provided by the commercial pest control to prevent pest entry and clean and proper disposal of food waste in the kitchen. The facility reported a census of 48 residents. Findings include: During an observation on 2/10/25 at 10:06 AM the back door of the kitchen adjoins the laundry room. Multiple pest traps were noted throughout the kitchen and into the laundry room. During an interview on 2/10/25 at 10:06 AM Staff J, Laundry stated there are more pest traps in the cupboards and they are roach traps. Staff J stated that roaches have been in the laundry bins and occasionally in the clothes. Staff J stated she had killed a roach this morning. During an observation on 2/11/25 at 9:41 AM, a large kitchen trash lid was on the floor and food debris and spatters were on the wall behind the trash and on the side of the oven which was next 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 observations, clinical record review and staff interviews the facility failed to assure services were provided to meet acceptable standard of practice during medication administration for 2 out of 5 residents (Residents #5 and #47). The facility reported a census of 48 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed a diagnosis of dementia. The Care Plan for Resident #5 revealed an impaired cognitive function or impaired thought processes due to dementia and directed staff to administer medications as ordered, monitor and document side effects, cue, reorient and supervise as needed. On 2/11/25 at 9:32AM Resident#5 was in her room with medications in a cup, no staff were in the room to provide supervision. Staff D, Licensed Practical Nurse (LPN) was across the hall by the medication cart. During an interview on 2/17/25 at 1:17 PM, Staff D, LPN stated Resident #5 did not have difficulty taking medications and was aware the facility policy directed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews, the facility failed to follow the rehabilitation directives and the rehabilitation staff failed to provide restorative care for a resident (#35) in need of their services. The facility reported a census of 48 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #35 revealed there were 0 days for restorative care provided. The Care Plan for Resident #35 revealed that she had activities of daily living deficit due to the left lower leg fracture and will participate in the restorative plan 3 times weekly. The document titled Restorative Therapy Program dated 10/24/24 signed by the Physical Therapist revealed: a. Identified Resident #35. b. The frequency of the program to be completed 3-5 times a week for 6 months. c. Passive/Active Range of Motion (ROM) 1. [NAME] Therabands 2-3 times for 15 repetitions, both elbow flexion, extension and shoulder extension rotation. 2. Continuous cycling for upper body for 15 minutes…

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 interview, clinical record review, and facility policy review, the facility failed to ensure Provider notification and timely response to Pharmacy recommendations for 2 of 5 residents (Resident #29 and #36) reviewed for unnecessary medications. The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Diagnoses included Bipolar Disorder, Post Traumatic Stress Disorder (PTSD), and adjustment disorder with depressed mood. Resident #29 required anticonvulsant medication. The Care Plan, revised on 5/08/24, revealed Resident #29 had focus area for antidepressant medication related to poor nutrition and Bipolar mood disorder with interventions to administer antidepressant medications as ordered by physician, and to monitor/document side effects and effectiveness of medication every shift. The Medication Administration Record (MAR), dated…

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 facility record review and staff interviews, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program in place to assist in the provision of quality care for residents. The facility identified a census of 48 residents. Findings include: Review of the Department of Inspections and Appeals web site entity search reveals this facility has repeat deficiencies the past two years for infection control, professional standards and clean environment. During an interview on 2/18/25 at 9:39 AM, the Administrator acknowledged the facility had repeat deficiencies the past two years. She stated there were attempts to assist the kitchen staff with training. She stated all of the staff in the kitchen are new. During an interview on 2/18/25 at 9:53 AM, the Regional Director of Operations stated the root cause was due to the turn over in the kitchen staff. She stated that on 2/6/25 she visited the kitchen, identified concerns and began designing a Performance Improvement Plan (PIP) that will make progress and provide support for the kitchen 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, resident and staff interviews, the facility failed to maintain safe, clean, sanitary and orderly bathroom facilities for 5 of 8 resident bathroom facilities reviewed. (Resident #2, #3, #4, #6, #7) The facility reported census was 52. Findings include: 1. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/14/24, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #2 required some supervision, but primarily independent with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnoses included Non-Alzheimer's dementia, renal insufficiency, congestive heart failure, coronary artery disease and bipolar disorder. During an observation on 12/9/24 at 12:10 p.m. Resident #2 was resting quietly in bed. Bedroom floors appeared dirty and gritty. The bathroom floor had a blanket next to the toilet and wall tiles above the toilet were missing. (See photos 16B 12.9.24 and 16B 12.9.24 (2).) The following morning on 12/10/24 at 8:35 a.m. The blanket…

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, resident and staff interviews, the facility failed to maintain an environment in good and orderly condition for for 5 of 8 resident rooms reviewed (Residents #1, #2, #3, #5, #7). The facility reported census was 52. Findings include: 1. According to a Annual Minimum Data Set (MDS) with a reference date of 10/10/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognitive status. Resident #1 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included Alzheimer's, renal insufficiency, neurogenic bladder, benign prostatic hyperplasia, atrial fibrillation, diabetes mellitus, chronic obstructive pulmonary disease, respiratory failure, congestive heart failure, peripheral vascular disease. During an observation on 12/9/24 at 12:00 p.m. Resident #1 was resting quietly in bed. The room floors appeared dirty and gritty and a piece of baseboard was detached from the wall near bathroom door. (See photo 25B 12.9.24). Upon returning 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, staff interview and policy review, the facility failed to promote care for residents in a manner and environment that maintains each resident's dignity and right to be served and provided meals in a timely manner and in accordance with the facility's dining schedule. The facility reported a census of 52 residents. Findings include: During an observation of lunch service 3/11/24 beginning at 12:10 PM, observed residents seated in the main dining room waiting for lunch to be served. One kitchen staff served meals to the residents in the dining room. At 12:45 PM, five residents still waiting to be served lunch. At 12:54 PM a resident who was in the dining room since the beginning of the observation asked where his food was. The resident served lunch at 12:55 PM, with the last residents being served in the dining room at 12:55 PM. Room trays did not start being served to residents choosing to eat in their rooms until 1:10 PM. During an observation of lunch service 3/13/24 beginning at 11:50 AM, observed residents seated in the main dining room waiting for lunch 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.

Based on observations, faciliity document review, and staff interviews, the facility failed to maintain a safe, clean, and homelike environment due to holes multiple walls, uneven hallway flooring, collapsing soffits throughout the exterior of the building, and strong odor in the central family room. The facility reported a census of 52 residents. Findings include: A direct observation on 03/11/24 at 01:46 PM revealed at least one cloth recliner in the primary living had a strong odor that permeated the living area. A direct observation on 03/11/24 at 03:31 PM revealed the walls in Resident # 252's room had uncovered, large holes in the dry wall behind a recliner. Also observed numerous large chips in the paint near the base of the bed. The baseboard heaters dented, chipped, and bent out of shape. A direct observation on 03/11/24 at 03:32 PM revealed an uneven space in Hallway C that this surveyor nearly tripped over. The tile appears visibly damaged with a dip in the center. A direct observation on 03/12/24 at 09:17 AM showed the baseboard heaters in Resident # 21's room to be…

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

Based on observations, staff interviews and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility reported a census of 52 residents. Findings include: During an observation 3/11/24 at 1:07 PM, Staff D, Certified Medication Aide (CMA) assisted a resident in the dining room during lunch service, assisting with feeding the resident and touching utensils and glassware. Staff D stood up and moved two glasses of fluid for another resident, touching the rim of both glasses. Staff D did not sanitize her hands before or after touching the rims of the glasses. Staff D sat back down and resumed assisting a resident with eating, touching the table and then picking up a piece of bread with both hands to tear apart and give to the resident to eat. Staff D did not sanitize her hands between residents, or before and after touching surfaces and food. During an observation 3/13/24 at 8:34 AM, Staff D assisted two residents eating breakfast. Staff D went back and forth between the two…

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

Based on clinical record review, observations, resident interview and staff interviews, the facility failed to accommodate residents needs with assurance of accessibility to call lights within resident's reach and provision of appropriate and adaptive equipment for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) for Resident #6, dated 12/24/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The MDS further documented diagnoses to include medically complex conditions, orthostatic hypotension and a neurogenic bladder. The MDS revealed the resident had impairment in range of motion on both sides of her upper extremity (shoulder, elbow, wrist and hand). The Care Plan for Resident #6, with a revision date of 5/3/21, with a focus area for activities of daily living (ADL), documented an ADL deficit related to contracture, above knee amputation (right), neurogenic bladder, anemia, depression/anxiety and rheumatoid…

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 interview and staff interview, the facility failed to keep accurate advance directives per a residents wishes for 1 of 3 residents sampled (Resident #21). The facility reported a census of 52. Findings include: Record review of Resident #21's paper chart noted an Iowa Physician Orders for Scope of Treatment (IPOST) with a status of do not resuscitate dated (DNR) [DATE]. Continued record review in the electronic health record (EHR) showed an IPOST status of full code. This finding discrepant with a status of DNR. In an interview on [DATE] Staff D, CMA, stated the IPOST status of a resident can be obtained through the electronic health record (EHR). Staff D indicated that is where a staff member looks to find the IPOST status. Staff D pulled out their EHR application on their phone, looked up Resident #21, and stated Resident #21's IPOST status as full code. In an interview on [DATE] at 04:07 PM Staff C, LPN, stated they believe they are required to check the paper chart…

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, family interview and staff interview, the facility failed to notify the resident and resident representative in writing of the discharge as soon as practical for 1 of 1 residents (Resident #51) who were sampled for closed record review for facility initiated discharge. The facility also failed to notify the Long Term Care Ombudsman for 1 of 1 residents who transferred to the hospital (Resident #6). The facility reported a census of 52 residents. Findings include: 1. Review of the Progress Notes for Resident #51 revealed the resident discharged from the facility on 1/4/24 with the reason for discharge being a need for secure placement. The note documented the resident driven by her daughter and son in law in a private vehicle and discharge instructions reviewed with the daughter. Review of the electronic record and hard copy record at the facility for Resident #51 lacked documentation of the notification in writing for discharge of the resident to the resident or resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to notify the resident's representative of the facility policy for bed hold, including reserve bed payment, for 1 of 1 residents (Resident #6) who were reviewed for hospitalization. The facility reported a census of 52 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE] and the facility's computer software program used for electronic medical record documentation revealed Resident #6 had discharged from the facility on 1/2/24 to the hospital and reentered the facility on 1/5/24. The clinical record lacked documentation, either in writing or verbally, of notification to the resident's representative of the facility policy for bed hold, including reserve bed payment, when Resident #6 discharged and transferred to the hospital on 1/2/24 with an anticipated return. Review of the resident's clinical record showed the resident had a Power of Attorney (POA) in place. During an interview 3/14/24 at 12:44 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review, and staff interviews the facility failed to re-submit a Pre-admission Screening and Resident Review (PASRR) with new psychiatric diagnosis for 2 of 2 residents (Resident #6 and #12) reviewed for PASRR requirements. The facility additionally failed to follow PASRR recommended specialized services as care planned (Resident #12) and further failed to care plan PASRR recommended services (Resident #6). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #12 required antipsychotic, antianxiety, and antidepressant medication. Diagnoses included anxiety disorder and depression. The Care Plan focus area, initiated 08/15/23, revealed Resident#12's PASRR identified a need for specialized services due to diagnoses of major depressive disorder and anxiety disorder. The Care Plan indicated a goal that Resident #22 would have individual therapy services by a licensed therapist to address…

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 interview, the facility failed to fully review and revise the comprehensive care plan for 1 of 3 residents (Resident #27) who were sampled for care plan review related to catheter care. The facility reported a census of 52. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #27 reflected the resident occasionally incontinent and did not have a catheter. The Care Plan for Resident #27, with a revision date of 2/21/24, under the focus area for incontinence, documented the resident is incontinent of urine due to impaired mobility, diuretic use, chronic kidney disease stage 3 and benign prostatic hyperplasia (enlarged prostate). The care plan directed staff to assist the resident to the bathroom throughout the day, assist with peri cares twice daily and as needed, assist with changing the adult protection pad and monitor urine. The care plan did not have a focus area or interventions/tasks for catheter care. Review of the electronic health record 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, staff interviews, clinical record review, and facility document review, the facility failed to administer insulin as ordered and further failed to administer the correct dose of an antipsychotic medication for 1 of 6 residents (Resident #16) reviewed for medication administration. The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #16 required insulin injections each day of the look back period and required anti-psychotic medication on a routine basis. Resident #16 diagnoses included: diabetes mellitus, schizophrenia, anxiety disorder, depression, and borderline personality disorder. The Care Plan, revised on 01/19/24, revealed focus area for diabetes mellitus diagnoses and instructed staff to administer medications as Physician ordered. The Care Plan focus area for impaired cognitive function additionally instructed staff to administer medications as ordered. The Care Plan, informed that Resident #16 is at risk 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 observations, clinical record review, staff and family interviews, the facility failed to provide adequate oral care for 3 of 5 residents reviewed (Resident #9, #25 and #29) who needed assistance with oral hygiene as directed in their respective individual plans of care. The facility additionally failed to provide daily assistance with dressing and grooming (Resident #5) and twice weekly bathing (Resident #22) for 2 of 8 residents reviewed for activities of daily living. The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set, dated [DATE] for Resident #9 revealed a diagnosis of dementia, pneumonia, gastroesophageal reflux disease (GERD) and required assistance of 1 for activities of daily living (ADL) to include oral care. Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10 suggesting a moderate impairment. The Care Plan dated 3/3/24 for Resident #9 directed staff to provide the aid of 1 staff member for grooming, hygiene, bathing and oral cares. An…

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

Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to report an allegation of abuse within 24 hours of the event. (Resident #1) The facility reported census was 49. Findings include: According to a Minimum Data Set (MDS) with a reference date of 8/6/23, Resident #1 had a Brief Mental Status (BIMS) score of 15 out of 15 indicating an intact cognitive status. The MDS documented the resident required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included chronic obstructive pulmonary disease. The Care Plan dated 8/15/23 documented Resident #1 is in need of Specialized Services due to major depressive disorder and anxiety disorder. The care plan directs staff that the resident is to receive therapy services from behavioral health. The care plan also documented the resident had a recent trauma in her life due to the death of her daughter and is at risk for post traumatic stress disorder. In an interview on 10/25/23 at 3:10 p.m. Staff C, Certified Nurse…

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

Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to prevent further potential of abuse by not separating the alleged perpetrator from the alleged victim. (Resident #1) The facility reported census was 49. Findings include: According to a Minimum Data Set (MDS) with a reference date of 8/6/23, Resident #1 had a Brief Mental Status (BIMS) score of 15 out of 15 indicating an intact cognitive status. The MDS documented the resident required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included chronic obstructive pulmonary disease. The Care Plan dated 8/15/23 documented Resident #1 is in need of Specialized Services due to major depressive disorder and anxiety disorder. The care plan directs staff that the resident is to receive therapy services from behavioral health. The care plan also documented the resident had a recent trauma in her life due to the death of her daughter and is at risk for post traumatic stress disorder. In an interview on 10/25/23…

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.

Based on clinical record review and staff interview the facility failed to properly dispense controlled medications in accordance with professional standards of practice. (Resident #2) The facility reported census was 49. Findings include: According to a Minimum Data Set (MDS) with a reference date of 1/17/23, Resident #2 had a Brief Mental Status (BIMS) score of 14 out of 15 indicating an intact cognitive status. The MDS documented the resident required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included coronary artery disease, respiratory failure, chronic obstructive pulmonary disease, benign prostatic hypertrophy and arthritis. The MDS documented the resident received scheduled and as needed (PRN) pain medication. In an interview on 10/24/23 at 1:40 p.m. the Director of Nursing stated on 2/9/23, she was alerted to a discrepancy with Resident #2's liquid morphine. During a shift change narcotic count on 2/9/23 at 6:00 a.m. it was noted that only 0.25 milliliters remained in the bottle when the controlled…

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.