Osage Rehab and Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review the facility failed to implement interventions for 1 of 1 resident with unstageable pressure ulcers. The facility reported a census of 25 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS documented 2 unstageable pressure ulcers (a severe skin wound where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the dead tissue is removed). The MDS listed the 2 unstageable pressure ulcers as not present during her admission to the facility and were acquired during her stay at the facility. The Care Plan Problem revised 12/12/25 indicated Resident #4 admitted with pressure areas to her coccyx (area in the lower back just above the buttock), left ischium (hip), and right ischium. In addition, she had pressure area to her left lateral (side) ankle, right lateral ankle,…

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, facility document review and staff interviews, the facility failed to post the daily staff posting with the census and facility name. The facility reported a census of 25 residents. Findings include:An observation on 12/15/25 at 3:17 PM observed the facility didn't have the daily staff posting didn't contain the resident census or the facility name. An observation on 12/16/25 at 3:20 PM observed the facility didn't have the daily staff posting didn't contain the resident census or the facility name. An observation on 12/17/25 at 3:42 PM observed the facility didn't have the daily staff posting didn't contain the resident census or the facility name. During an interview on 12/18/25 11:41 AM, the Administrator reported the overnight nurses did the daily staff postings. She reported the nurses fill out the nurses and CNA number of staff and hours totaled each shift. She reported she didn't believe the staff put the census of it. On 12/18/25 at 11:44 AM observed with the Administrator the daily staff posting didn't contain the resident census or the facility name.

Based on facility record review, staff interview and policy review, the facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities are necessary. The facility reported a census of 25 residents.Findings include:Review of the facility QAA sign in sheets revealed the facility didn't have the Infection Preventionist present at the March, May, August or November quarterly meetings. In addition, the facility didn't have the Director of Nursing (DON) present at the May or November quarterly meetings. The Administrator didn't attend the August quarterly meeting. On 12/17/25 at 10:30 AM the Administrator reported she didn't know the facility didn't have all required staff at the QAA meetings. She reported the facility struggled with staffing. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Committee dated July 2016 lacked direction on the required amount needed at the QAA meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and policy review the facility failed to use enhanced barrier precautions (EBP infection control measures, requiring healthcare workers to wear gowns and gloves for high-contact care) when providing routine catheter care for 1 of 1 resident reviewed (Resident #9). The facility reported a census of 25 residents. Findings include:Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS listed her as dependent (staff does all the effort) on staff for toileting hygiene (perineal hygiene). The MDS documented she used a catheter. The MDS included a diagnosis of neurogenic bladder (a condition where nerve damage to the brain, spinal cord, or peripheral nerves disrupts the signals controlling bladder function, leading to loss of control, incontinence, urinary retention, or incomplete emptying) Resident #9's Order Summary Report dated 7/14/25 documented 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 facility policy and staff interviews, the facility failed to have a qualified Infection Preventionist to monitor and provide oversight to the facility's infection prevention program. The facility reported a census of 25 residents.Findings include: On 12/15/25 at 10:10 AM, the Administrator reported the facility didn't have a qualified Infection Preventionist for the building. The Administrator reported the Assistant Director of Nursing (ADON) started taking the classes but had not completed them. On 12/18/25 at 10:35 the ADON reported she is currently taking the classes to become a qualified Infection Preventionist. The facility policy titled Infection Prevention and Control Program documents the program is coordinated and overseen by an Infection Prevention Specialist.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and staff interviews, the facility failed to provide pneumococcal vaccine as requested for 2 of 5 residents reviewed (Resident #4 and #15). The facility reported a census of 25 residents.Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #4 didn't receive a pneumococcal vaccine due to the facility not offering the vaccine. A Pneumococcal Conjugate Informed Consent form dated 9/24/25, signed by the Resident #4, indicated that she received information and gave consent to receive the vaccine. Resident #4's Electronic Health Record (EHR) lacked documentation of receiving the pneumococcal vaccine. On 12/17/25 at 2:58 PM the interim Director of Nursing (DON) reported Resident #4 didn't get the pneumococcal vaccine as consented. The undated facility policy titled Infection Prevention and Control Program documented to try and help…

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 and family interview, the facility failed to provide transportation for a resident from a physician's appointment for which resulted in the family member transporting the resident back to the facility for 1 of 4 resident reviewed. (Resident #1) The facility identified a census of 26 residents. Finding include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The resident required partial to moderate assistance for activity of daily living (ADL) and used a wheelchair for mobility. The MDS included diagnoses of hypertension (high blood pressure), aphasia (difficulty talking), cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis of one side of the body, resulting from brain damage) and anxiety. Resident #1's admission Orders dated 10/7/24 listed they had a follow up appointment scheduled on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, photos taken during observation, resident, and staff interview, the facility failed to ensure all residents who resided on the East end of the building resided in a clean, sanitary, and homelike atmosphere. The facility identified a census of 28 residents. Findings include: According to a Department of Health and Human Services Centers For Medicare and Medicaid Services form 2567 with a survey completion date of 11/18/22, the facility received a deficiency for F584. The deficiency referred to a buildup of a black substance with the appearance of mold on the pipes of the heating elements in resident rooms on the East end of the building. The Maintenance Supervisor at the time indicated the heating and cooling elements in all of the rooms on the East side of the building contained hot water that flowed through the pipes in the winter and each box in the resident's rooms the hot water flowed through the pipes and in the summer the water changed from hot to cold. Related 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 resident interview, staff interview, Alarm Response Report forms, and facility policy review, the facility failed to answer resident call lights in a timely manner and within the regulated 15-minute time frame for 2 residents reviewed (Residents #6 and #1). The facility identified a census of 28 residents. Findings include: 1. During an interview on 4/3/25 at 3:23 PM Resident #6 confirmed she timed her call light on for over 15 minutes, which pissed her off. Review of the facility's Alarm Response Report form for a one (1) week period of time from 3/27/25 thru 4/2/25 revealed the facility failed to answer her call light within the allotted 15-minute time frame on the following dates: a. 3/27/25 at: i. 11:10 AM for 21:42 minutes ii. 5:44 PM for 18:49 minutes iii. 9:53 PM for 19:50 minutes iv. 9:53 PM for 10:30 minutes v.10:13 PM for 26:02 minutes. b. 3/30/25 at 1:23 AM for 17:03 minutes. 2. During an interview on 4/3/25 at 2:50 PM Resident #1, identified by the facility as interviewable, confirmed she recently timed her call light as on for two (2) hours on an unknown…

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 resident interview, staff interview, Alarm Response Report forms, and facility policy review, the facility failed to answer a resident's call light in a timely manner and within the regulated 15-minute time-frame for 1 of 3 residents reviewed (Resident #6). The facility identified a census of 31 residents. Findings include. During an interview on 2/27/25 at 3:30 PM Resident #6 reported a couple weeks ago she timed the time it took for someone to answer her call light, it stay on from approximately 1:30 AM till 5:30 AM. At that time, she used her cell phone which gave her a feeling of anger and tired of being ignored. Resident #6 added other times she timed her call light on for 45 minutes on the 3rd shift which caused her to lose control of her stool (bowel movement) so she sat in her own poop, this caused her to feel unhappy because if the staff answered her light timely she wouldn't become incontinent. Resident #6 explained in October they left her in bed for 14 hours against her will because the facility failed to provide enough staff to get her up as she required three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to implement Care Plans for one (1) resident reviewed (Resident #6) The facility reported a census of 31 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 Care Plan Focus revised 10/11/23 indicated Resident #6 had a risk for falling related to gait/balance problems, and incontinence. The Interventions directed to have the call light in reach and encourage her to use as needed (PRN). Resident #6 required prompt response to all requests for assistance. During an interview on 2/27/25 at 3:30 PM Resident #6 reported a couple weeks ago she timed the time it took for someone to answer her call light, it stay on from approximately 1:30 AM till 5:30 AM. At that time, she used her cell phone which gave her a feeling of anger and tired of being ignored. Resident #6 added other times she timed 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.

Based on clinical record review, staff interview and facility policy review the facility staff failed to follow Physician Orders for 1 of 3 residents reviewed (Resident #3). The facility identified a census of 31 residents. Findings include: A faxed Physician Order form signed by the Physician on 1/29/25 reflected Resident #3 received six (6) marks (bites) on her left arm from her cat that measured 0.1 centimeters (cm) by (x) 0.1 cm. The Physician ordered the staff to cleaned the areas on the resident's left hand with normal saline, apply by Triple Antibiotic Ointment (TAO) and cover with a bandage two (2) times a day (BID) and as needed (PRN) until healed. Resident #3's January and February 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) forms lacked the prescribed treatment orders, indicating the treatment didn't get completed as ordered. According to an email 3/4/25 at 1:56 PM the Administrator indicated Staff A, Licensed Practical Nurse (LPN), confirmed the January and February 2025 MARs and TARs didn't have the treatment order. 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 record review, policy review, and staff interview the facility failed to provide the resident or the resident's legal representative with a Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNF/ABN) and Notice of Medicare Non-Coverage (NOMNC) to document an appeal decision and the date of notification of Medicare non-coverage for 1 of 3 residents (Resident #10) sampled. The facility identified a census of 27 residents. Findings include: Resident #10's Electronic Census Record detailed the Resident admitted into Medicare Part A skilled services on 5/09/24 and discharged off on 8/16/24. The admission Minimum Data Set (MDS) assessment dated [DATE] listed a diagnoses of septicemia, muscle weakness, dysphagia and urinary tract infection and detailed Resident #10 had received speech-language pathology treatment and physical therapy treatment.The MDS revealed a Brief Interview for Mental Status score of 3 out of 10 indicating severe cognitive impairment. A review of Resident #10's Progress Notes…

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 interview and staff files review, the facility failed to do a background check on 1 of 5 staff reviewed. The employee file for Staff A, Certified Medication Aide (CMA) lacked a criminal background check. The facility reported a census of 27 residents. Findings include: A letter from the Chief Human Resources Officer (CHRO) and signed as accepted by Staff A on 12/5/22, documented that the CHRO was pleased to confirm an offer of conditional employment for the position of full time Certified Nurse Aide effective on 12/5/22. A review of Staff A's folder on 11/13/24, revealed that a background check was not in her file. It revealed a hire date of 12/5/22. On 11/13/24 at 1:17 PM, Staff B, Business Office Manager (BOM), stated the facility did not have a criminal background check for Staff A. This BOM stated she had a call out to the one Human Resource person who is left for the corporation, but the HR person is out on vacation until the 11/19/24. Staff B stated she did leave a message. This BOM stated she had an email out to 2 other staff as well. One who does payroll and one who…

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, policy review and staff interviews, the facility failed to complete a baseline care plan for 1 of 2 residents reviewed (Resident #27). The facility reported a census of 27 residents. Findings include: The Census tab in the Electronic Health Record (EHR) documented Resident #27 admitted on [DATE] and discharged on 10/26/24. Review of the Nursing Data Assessment for Resident # 27 completed on 10/22/24 documented the resident admitted to the facility post left knee replacement. Review of Resident #27's EHR lacked a completed baseline care plan. On 11/13/24 at 12:07 PM, the Administrator reported the baseline care plan for Resident #27 was not completed. During an interview on 11/13/24 at 12:16 PM, the Director of Nursing reported the baseline care plan should be completed within 72 hours of admission. Review of the facility policy for baseline care plans revised December 2016 documented a baseline plan of care to meet the resident's immediate needs shall be developed for each…

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

Based on clinical record review, resident interview, staff interviews and policy review, the facility failed to ensure residents had at least 2 baths/showers per week for 2 of 3 residents reviewed for bathing (Resident #4 and #6). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #6 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The resident had a diagnosis of multiple sclerosis (an autoimmune disease where tissue hardens or stiffens)and required assistance from staff with bathing. The Care Plan revised 5/5/22 for Resident #6 revealed a focus area of an activity of daily living self care deficit related to limited mobility and directed staff to provide 2 staff participation with bathing. During an interview on 11/12/24 at 3:39 PM, Resident #6 revealed she was not consistently receiving showers as scheduled. Review of Electronic Health Record (EHR) for Resident #6 lacked documentation of showers/baths being offered or provided on the following dates: a. 10/4/24 b.10/11/24 c.…

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

Based on clinical record review, resident interview and staff interview, the facility failed to ensure completion of physician ordered treatments for 1 of 2 residents (Resident #6). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #6 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The resident had a diagnosis of multiple sclerosis (MS) (an autoimmune disease where tissue hardens or stiffens)and required assistance from staff with bathing. During an interview on 11/12/24 at 3:39 PM, Resident #6 revealed the dressing for her peripherally inserted central catheter (PICC) line was not consistently being completed as ordered by the physician. The Care Plan initiated 9/20/21 for Resident #6 revealed the resident had MS with a goal to remain free of complications or discomfort related to MS and directed staff to contact the provider right away if noticed signs or symptoms of PICC line complications. The Care Plan further directed staff to change the PICC line dressing using sterile…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to do pre and post dialysis assessments for 1 of 1 resident who received hemodialysis (use of a machine to filter waste out of the kidneys) (Resident #24). The facility reported a census of 27 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented Resident #24 admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS), revealed a score of 9 out of 15, which indicated Resident #24 had moderate cognitive impairment. This MDS documented that diagnoses for Resident #24 included End Stage Renal Disease (ESRD). This MDS documented this resident received hemodialysis. A Care Plan initiated on 3/18/24, directed that Resident #24 needed hemodialysis related to renal failure, ESRD. It directed that Resident #24 would have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date. It directed staff to encourage resident to go for the scheduled dialysis…

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 interview and facility policy review, the facility failed to follow the Care Plan for 1 of 3 residents reviewed (Resident #2). The facility identified a census of 33 residents. Findings included: The Care Plan Focus dated 5/16/23 indicated Resident #2 required a feeding tube related to a swallowing problem. The Interventions directed the following: a. Dependent on staff with tube feedings and water flushes. b. Monitor, document and report to the Physician as needed (PRN) for the following: Aspiration, shortness of breath (SOB), abnormal breath/lung sounds and nausea and vomiting. c. Resident #2 required the head of bed (HOB) elevated 45 degrees during and thirty minutes after a tube feeding. During an interview on 7/15/24 at 2:27 PM Staff C, Certified Nursing Assistant (CNA), indicated Staff B, Registered Nurse (RN), came to her and reported Resident #2 just threw up and she needed assistance to reposition him. When the staff members entered Resident #2's room, they found him responsive (able to react) but lethargic (excessive tiredness).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review, the facility failed to complete thorough assessments and interventions for a 2 of 3 residents following a condition change (Residents #1 and #2). The facility identified a census of 33 residents. Findings include: 1. Resident #2's Progress Notes dated 6/27/24 reflected the following at: a. 6:09 AM Staff changed Resident #2's catheter per his request due to it bothering him. The nurse changed the catheter and noted some blood after placement. b. 7:28 PM Blood noted in the catheter drainage bag Resident #2's Progress Notes lacked assessments on his catheter between 6:09 AM and 7:28 PM. In addition, his record lacked additional assessments after 7:28 PM until his discharge to the hospital on 6/28/24 at 3:00 PM. The Hospital's History of Present Illness report dated 6/28/24 indicated Resident #2 presented from the emergency department (ED) of an outlying facility for septic shock. The nursing facility found him unresponsive, covered with…

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

Based on personnel file reviews, facility policy review and staff interview, the facility failed to assure 2 of 6 staff met the requirements for Dependent Adult Abuse Training (Staff A and Staff B). The facility reported a census of 33 residents. Findings include: Review of Staff A, Certified Medication Aide (CMA), personnel file revealed a Dependent Adult Abuse training completed on 1/9/19 and was good for five years from the date in which would need to be completed by 1/9/24. The file lacked any further Dependent Adult Abuse training. Review of Staff B, Certified Nursing Assistant (CNA), personnel file with the start date of 3/16/23 lacked any documents of Dependent Adult Abuse Training. On 4/9/24 at 1:27 PM the Administrator reported Staff A, CMA, and Staff B, CNA, were completing the training right now but acknowledged it was late. The Abuse Prevention Program & Reporting policy revised April 2023 directed each employee shall be required to complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial…

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

Based on observation, policy review, and staff interview, the facility failed to serve food under sanitary conditions, in order to reduce the risk of contamination and food borne illness. The facility reported a census of 33 residents. Findings include: On 4/8/24 at 5:30 PM, observed Staff D, Cook, wash her hand and applied gloves. Staff D started the supper service, she touched the containers of pasta salad and fruit to remove the lids off of both containers with the gloved hands. Staff D then grabbed a resident's menu they filled out and set in front of her on the steam table. Staff D grabbed a plate and set it on the counter and took a chicken salad sandwich out of the pan placing it on the plate. Staff D then took the utensil and dished up pasta salad on to the plate and then with a different utensil dished up the fruit into a bowl. Staff D then with the gloved hands grabbed a cookie and wrapped it up and placed it all on a tray. Staff D proceeded to do then same thing with the next 15 resident's meals going between surfaces touching the menu, plates, bowls, utensils and food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews and policy reviews, the facility failed to ensure staff treated residents with dignity and respect for 1 of 5 residents reviewed (Resident #5). The Facility reported a census of 33 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) Score of 14 indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), diabetes, schizoaffective disorder (mental health disorder), borderline personality disorder (mental health disorder), anxiety and traumatic brain injury. During an interview on 4/8/24 at 1:22 PM, Staff C, Certified Nurse Aide (CNA), reported about a month ago she was in a room assisting Staff B, CNA, with Resident #5 to change her. During the process Staff B told Resident #5 you smell like piss. Staff C reported after they were done changing the resident and Staff B left the room, Resident #5 cried because she was upset about what Staff B…

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

Based on observation and staff interviews the facility failed to maintain a clean and safe homelike environment when the flooring in the dinning room showed multiple areas where the vinyl had been ripped. The facility also failed to ensure the carpet in multiple hallways throughout the facility was in good condition without stains or frays. The facility reported a census of 33 residents. Findings include: During the initial unannounced walk through of the facility on 8/27/2023 at 10:10 AM to 10:40 AM revealed the following: a. Four (4) spots in the dinning room that appeared to have patched vinyl that was replaced in the past. Now had the old vinyl around it being lifted and exposing a white underlay. b. Three (3) areas in the facilities hallways to residents rooms where the carpet was observed to be lifted and fraying, and multiple areas throughout the facility with large discolorations. During an interview with the Administrator on 8/29/23 at 3:51 PM revealed she does not have a current plan in place for replacing the flooring, she did reveal that when she started her position at…

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

Based on record review and staff interviews the facility failed to Care Plan 1 of 2 residents Specialized Services that were instructed to be care planned on his Preadmission Screening Resident Review (PASRR) Level II document (Resident #31). The facility reported a census of 33 residents. Findings include: Record review of Resident #31 PASRR dated 3/6/23 documented the need for the following Specialized Services: a. Ongoing medication review by a psychiatrist or psychiatric nurse practioner b. Individualized therapy Record review of Resident #31 current Care Plan on 8/29/23 lacked documentation of how the facility was going to meet the needs of his PASRR Specialized Services for medication review by a psychiatrist or psychiatric nurse practioner and individualized therapy. During an interview with the facilities Director of Nursing and Administrator on 8/29/23 at 3:49 PM revealed they would expect all Residents that have PASRR Level II Specialized Services be apart of the residents Care Plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to code a resident admitted on an anti-coagulant (blood thinner) medication and a diuretic (removes excess water in the body) medication for 1 of 5 residents reviewed for medications (Resident #19).The facility also failed to develop a comprehensive Care Plan within 7 days of the completion date of the Minimum Data Set (MDS) for 1 of 1 new admissions reviewed (Resident #32). The facility reported a census of 33 residents. Findings include: 1. Record review of Resident #19 Orders on 8/29/2023 documented the following orders: a. Furosemide (diuretic) 20 milligrams (mg) 1 tab daily b. Apixaban (anti-coagulant) 5 mg 1 tab twice a day Record review of Resident #19 Medication Administration Record (MAR) for 8/1/23 to 8/30/23 documented she had received her Furosemide and Apixaban as ordered for all 30 days. Record review of Resident #19 Care Plan on 8/29/2023 lacked documentation of side effects for anticoagulant and diuretic medications for staff 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 observation, clinical record review, and staff interview the facility failed to update the Care Plan for 1 of 1 resident reviewed for mood and behaviors (Resident #2). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 included diagnoses of schizoaffective disorder, borderline personality disorder, manic episode, anxiety, and a history of suicidal behaviors. A Brief Interview for Mental Status (BIMS) Score Assessment completed on 7/20/23 had a score of 8 indicating moderately impaired cognition. During an interview on 8/27/23 at 2:09 p.m. Resident #2 was observed crying throughout the interview. Resident reported she gets very emotional about most things. Review of the Electronic Health Record (EHR) on 08/29/23 at 4:15 p.m. revealed the Care Plan lacked documentation of mood or behavior needs and interventions. Further review revealed a Nurses Progress Note dated 8/6/23 documenting the nurse was notified by Resident #2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview the facility failed to follow physician orders for a gastrostomy tube (g-tube) (a g-tube is an opening into the stomach from the abdominal wall, made surgically for a tube for the introduction of food via a feeding tube) feeding for 1 of 1 resident reviewed for care of a g-tube (Resident #13). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 showed a Brief Interview for Mental Status (BIMS) to be severely cognitive impaired. The MDS included diagnoses of epilepsy, cerebral palsy, muscle weakness, dysphagia, lack of coordination, unspecified intellectual disability, acute respiratory failure, and encounter for attention to gastrostomy. The resident utilized a feeding tube requiring 51 percent or more of the total calories through the tube. During an observation on 8/28/23 at 11:37 a.m. Staff A, Licensed Practical Nurse (LPN) gave Resident #13 two cartons of…

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

Based on record review, staff interviews, and policy review the facility failed to ensure 1 of 2 residents reviewed for hospitalizations (Resident #11) was provided with standard nursing assessment and intervention when a known decline was occurring and the facility failed to assess, document, or update the doctor if changes were occurring for greater than 36 hours. The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) for Resident #11 dated 4/3/2023 documented a Brief Interview of Mental Status (BIMS) of 9 indicating she was moderately cognitively impaired. The MDS documented the need for limited assist assist of one (1) person for transfers, walking, dressing, and toilet use. It also documented diagnoses of diabetes, heart failure, hypertension, and seizure disorder. Record review of Resident #11 MDS log in the facilities Electronic Health Record (EHR) documented the following MDS's were completed: a. 5/6/23 - Discharge from facility return anticipated b. 5/10/23 - Entry Record review or Resident #11 Assessment in the facilities EHR lacked…

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

Based on observation and staff interview, the facility failed to ensure the treatment cart was locked for 2 of 2 treatment carts on the initial walk through of the building and the Nurse and Certified Medication Aide (CMA) responsible for the cart were not in sight. The facility reported a census of 33 residents. Findings include: 1. Initial walk through observation 8/27/23 at 10:00 a.m. revealed the treatment cart was unlocked and unoccupied just outside the west wing hallway. Three residents wheeled in wheelchairs past the cart and two residents sitting in wheelchairs within eight feet of the cart. At 10:10 a.m., Staff B, Certified Nurses Aid (CNA) approached the cart and locked the cart. 2. Observation 8/27/23 at 10:13 a.m. revealed the treatment cart for the East wing was unlocked and unoccupied. At 10:18 a.m. Staff B, CNA walked to the treatment cart and acknowledged it had been unlocked. She reported the nurse who was responsible for the cart and must have missed it. During an interview 8/28/23 at 9:00 AM Staff A, LPN reported staff is to lock the medication and treatment…

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.