Good Samaritan - Ottumwa

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident representative interview, resident interview, staff interviews, and the facility policy, the facility failed to maintain appropriate food temperatures for a breakfast room tray. The facility reported a census of 95 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, which indicated cognition intact. During an interview on 5/26/26 at 4:01 PM, Resident #8 when asked about the food at the facility stated she didn't like the food. Resident #8 explained sometimes the food was hot and the meat can be cold on the outside and warm on the inside. Resident #8 stated the meat could partially cooked, or partially frozen. Review of the breakfast menu for 5/28/26 revealed the meal to be served included french toast, sausage patty, mixed fruit cup, choice of hot or cold cereal, assorted juice, milk/beverageDuring an observation on 5/28/26 at 6:57 AM, Staff H, Dietary [NAME] conducted…

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 a call light within the reach of 1 out of 21 dependent residents (Resident #95) in the sample. The facility reported a census of 101. Findings include: The Minimum Data Set (MDS) for Resident #95, dated 10/24/2025, list of diagnoses included atrial fibrillation or other dysrhythmias (irregular heart rhythm) diabetes mellitus, Non-Alzheimer's dementia, anxiety disorder, depression, and respiratory failure. The MDS identified Resident #95 dependent on staff for transfers and could not walk. The Care Plan for Resident #95, date initiated: 10/03/25, included a Focus area to address The resident has an ADL (activities of daily living) self-care performance deficit R/T (related to) copd (chronic obstructive pulmonary disease). Interventions included, in part: TRANSFER - Transfer Between Surfaces: assist x 2 with sit to stand with large harness if weak use the total lift high back large sling. Date Initiated: 11/7/25. During an observation on 12/02/2025 at 10:39 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to respond to a weight loss in timely manner for 1 of 2 residents (Resident #104) reviewed for weight change. The facility failed to notify the physician of a weight loss in a timely manner which delayed the implementation of dietician recommended interventions. The facility reported a census of 101 residents. Findings include:Review of Resident 104's Minimum Data Set (MDS) assessment dated [DATE] revealed a diagnoses list which included hyperlipidemia, anxiety, depression, dementia, pain, and hypokalemia. A Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicated severely impaired cognition. The MDS indicated Resident #104 required set up assistance with eating.Review of the Care Plan, initiated on 12/23/22, revealed a Focus area to address The resident has potential for nutrition issues r/t (related to) dementia, hx (history) surgical wound, anxiety d/o (disorder), muscle wasting…

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 use proper hand hygiene techniques during the administration of an insulin injection and eye drops for 1 of 3 residents (Resident #3) reviewed during medication administration observation. The facility reported a census of 101 residents. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #3's diagnoses included type 2 diabetes Mellitus. A Brief Interview for Mental Status documented a score of 07 out of 15, which indicated severely impaired cognition. This MDS documented that Resident #3 received insulin injections 7 of the past 7 days of the review period. Review of the Medication Administration Record (MAR) for the month of December 2025, directed Humulin KwikPen Suspension Pen-injector (Insulin) 10 units be administered in the AM and PM. Staff A , Licensed Practical Nurse (LPN) signed the MAR on 12/3/25 to indicate the AM dose administered. Review of the MAR for the month of December 2025,…

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 and resident interview, the facility failed to implement and follow physician orders for application of an ace wrap for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 92 residents. Findings include: 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. The MDS revealed the resident had a diagnosis of heart failure. Clinical record review revealed an order dated 6/18/25 for an ace wrap to be applied to Resident #8's lower extremities in the morning and discontinued in the evening. Review of June, July and August 2025 Medication Administration Records found no documentation of ace wrap or compression stockings being used as ordered. Observation on 9/3/25 at 10:45 a.m. noted Resident #8 sat in his recliner with his feet elevated. Resident #8 wore socks and shoes, but no ace wrap or compression…

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 and staff interviews, facility staff failed to ensure prompt intervention to ensure supplemental oxygen was administered in accordance with physician orders and each resident's individual care plan for 2 of 3 residents reviewed (Resident #6, #7). The facility reported census of 92 residents. Findings include: 1.According to a Minimum Data Set (MDS) assessment with reference date 6/17/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score 14 out of 15, which indicated intact cognitive status. Resident #6 required moderate assistance with transfers, mobility and dependent assistance with dressing, toilet use and personal hygiene needs and determined as having a catheter and occasional incontinence of bowel. Resident #6's diagnosis included Parkinson's, coronary artery disease, gastroesophageal reflux disease, malnutrition, benign prostatic hypertrophy, and a right femur neck fracture. According to physician orders, Resident #6 was to receive oxygen at 2-3 liters per minute for shortness of breath as needed to keep his oxygen…

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 and staff interview, the facility failed to use enhanced barrier precautions (EBP) during peri care for 1 of 3 residents who required EBP (Resident #6). The facility reported a census of 92 residents. Findings include: According to a Minimum Data Set (MDS) with a reference date of 6/17/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score 14 out of 15, indicating intact cognitive status. Resident #6 required moderate assistance with transfers, mobility and dependent assistance with dressing, toilet use and personal hygiene needs and determined as having a catheter and occasional incontinence of bowel. Resident #6's diagnoses included Parkinson's, coronary artery disease, gastroesophageal reflux disease, malnutrition, benign prostatic hypertrophy, and a right femur neck fracture. The Care Plan initiated 7/1/25, revised on 7/22/25, revealed the following: The resident requires Enhanced Barrier Precautions (EBP) R/T (related to) indwelling catheter. The Intervention dated 7/22/25 revealed, [NAME] gown and gloves 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 observation, staff interviews, and policy review, the facility failed to ensure dignity to residents in the main dining room. Resident with soiled shirt of spilt drink and processed food propelled self near other residents eating thorough the dining area (Resident #71). The facility reported a census of 111 residents. Findings include: The Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #71 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition was severely impaired. Diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, dysphagia (indicates difficulty swallowing) and pain. The MDS revealed resident required supervision or touching assistance with eating and required a mechanically altered diet. The Care Plan revealed a focus area initiated 5/31/24 for ADL (Activities of Daily Living) self care performance deficit related to Alzheimer's disease. The intervention dated 5/31/24 revealed resident required assistance 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 staff interviews, electronic record review, Iowa Physician Orders for Scope of Treatment (IPOST) form, and facility polic review the facility failed to ensure consistent documentation of code status for 1 of 32 resident reviewed for advanced directives (Resident #67). The facility reported a census of 111 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 medical diagnoses for Parkinson's disease, respiratory disease and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The Care Plan revealed a focus initiated [DATE] for the resident, relayed had a terminal prognosis related to cancer and directed staff to review resident's advance care planning choices and assist other to respect choices. A document titled Iowa Physician Orders for Scope of Treatment IPOST dated [DATE] for Resident #67 was located at the nurse's station to review in the event of an emergency and indicated to complete…

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 interviews and policy review the facility failed to provide eating assist to maintain good nutrition to 1 of 3 residents reviewed (Resident #67). The facility reported a census of 111 residents. Findings include: The MDS assessment dated [DATE] revealed Resident #67 medical diagnoses included Parkinson's disease and respiratory disease. A BIMS score of 13 out of 15 indicated cognition intact. The Care Plan revealed a focus initiated at admit 8/27/24 for resident #67 titled, Eating. Interventions noted, resident required hand over hand guidance, reminding, prompting and cueing. Electronic record revealed admit weight on 9/4/24 weighed 198.8 pounds and on 10/2/24 weighed 182.8 pounds, an 8.75% weight loss. Progress notes revealed Registered Dietician (RD) note dated 8/30/24, observed him eating and cannot hold silverware, needs assistance, discussed with resident #67 and he would like that. Telephone interview on 10/11/24 at 10:02 AM with the RD, confirmed…

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 interviews, and policy review, the facility failed to assist with scheduled repositioning, and toileting for a resident with impaired skin and a pressure ulcer risk for 1 of 3 residents observed for skin concerns (Resident #81). The facility reported a census of 111 residents. Findings include: The Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #81 diagnoses included Alzheimer's disease, dementia, urinary tract infection (UTI), pain, and cellulitis of buttocks. Resident required substantial, maximal assistance with transfers and sit to stand, had moisture associated skin damage. Resident #81 required pressure reducing devices for the wheelchair and the bed, a turning/repositioning program to manage skin problems. The Brief Interview for Mental Status (BIMS) exam scored 6 out of 15, which indicated cognition severely impaired. The Care Plan revealed a focus area revised 9/13/24 included potential of pressure ulcer development related 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, family interviews, staff interviews and the facility policy the facility failed to ensure adequate hydration for 1 of 3 residents reviewed. (Resident #81). The facility reported a census of 111 residents. Findings include: The Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #81 diagnoses of Alzheimer's disease, dementia, Urinary Tract Infection (UTI), pain, and cellulitis of buttocks, required substantial/maximal assistance with chair/bed to chair transfers and sitting to standing. the Brief Interview for Mental Status (BIMS) exam scored a 6 out of 15 indicated cognition severely impaired. The MDS revealed treatments that included a turning/repositioning program; and nutrition/ hydration interventions to manage skin problems. The Care Plan initiated date 4/8/24 for Resident #81 revealed a focus area for bladder incontinence related to confusion. The interventions included encourage resident to drink more fluids during morning and afternoon and limit…

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 the facility policy, the failed failed to use appropriate hand hygiene between resident's medication administration and failed to use proper technique for preparation of medication administration and touched resident's pills with their bare fingers for 2 of 5 oral medication administrations observed (Resident #13 and Resident #269). The facility reported a census of 111 residents. Findings include: 1. During an observation on 10/8/24 at 7:23 AM, Staff A, LPN (Licensed Practical Nurse) finished giving another resident his pills and did not use hand hygiene prior to prepping Resident #13 medications. Staff A opened a bottle of acetaminophen and tapped the bottle and then used her finger to push out 2 pills into a medication cup. Staff A then prepped oral medications for Resident #13. Staff A popped out the furosemide pill from the card and as she popped it out, her fingers touched the pill prior to the tablet going into the cup. Staff A popped out the resident's gabapentin and as she popped the pill from the card her fingers touched 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 and bathing records, the facility failed to ensure residents were provided adequate personal hygiene services to include at least two bathing opportunities per week for 2 of 4 residents reviewed (Residents #3 & #9). The facility reported census was 110 residents. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of 3/28/24, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11 indicating a mildly impaired cognitive status. Resident #3 required maximal to dependent assistance with mobility, transfers, dressing, toilet use, and personal hygiene needs. Resident #3 was coded as always incontinent of bowel and bladder. Diagnoses included peripheral vascular disease, diabetes mellitus, & malnutrition. According to shower schedules, Resident #3 was to receive shower opportunities on Wednesdays and Saturdays. Bathing records during April and May 2024 indicated Resident #3 was not provided bathing opportunities as scheduled on 4/17, 5/4, 5/11, 5/15 and 5/18. According to the Minimum Data Set (MDS) 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 record review, bathing records, and staff interviews, the facility failed to provide sufficient staff to ensure resident needs were met and bathing opportunities are provided as scheduled for 1 of 3 residents reviewed (Resident #3). The facility reported census was 110 residents. Findings include: In an interview on 5/22/24 at 9:00 a.m. Staff O, staff scheduler, stated she schedules one nurse with two to three aides from 6:00 a.m. to 6:00 p.m. on the 300 hall and 400/500 halls. Then reduces to one nurse and two aides from 6:00 p.m. to 10:00 p.m. Staff O stated staffing parameters are based on census. In an interview on 5/21/24 at 3:00 p.m. Staff K, Certified Nurse Aide, stated two aides on 300 hall are sufficient to meet resident needs, however there are times weekly in which they may only have one aide working. In an interview on 5/21/24 at 3:05 p.m. Staff J, Certified Nurse Aide, stated she has worked evening shifts on 300 hall for seven months. Staff J stated two aides are needed on 300 hall to meet the needs of the residents, but noted at least once a week, they may…

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 policy review, the facility failed to maintain a clean, free from possible hazards, and homelike environment. The facility reported a census of 113 residents. Findings include: On 8/21/23 at 11:35 AM the Sunroom located between 300 and 400 hallways revealed the ceiling had various water stains. One area had an active water leak that was collecting into a large blue tote surrounded by two yellow caution wet floor signs. The area remained accessible to residents. One of the walls closest to the water filled tote had bookcases filled with books and puzzles for residents. On 8/21/23 from 12:19 PM to 12:45 PM, multiple residents entered the sunroom, and made their way around the large blue tote. One of the residents mentioned that a water leak appeared a while ago and the facility recently made some roof repairs but the water leak continued from the air conditioning ducts. On 8/22/23 at 10:30 AM an observation of 100 Hall, (a secured section of the building occupied by residents with memory deficit) revealed multiple walls 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time for 7 of 9 residents reviewed for staffing(Residents # 19, #22, #32, #49, #75, #100, and #362) . Residents and staff reported having low staffing caused missed or delayed cares. The facility reported a census of 113 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #100 dated 8/14/23 documented a Brief Interview of Mental Status (BIMS) as 15 which indicated intact cognition. The MDS documented admission to the facility on 2/9/23. On 8/21/23 at 2:10 PM, Resident #100 reported he had to wait sometimes up to 3 hours for a meal service. He also reported the facility did not consistently provide him a shower twice weekly due to staff not showing up. Clinical record review for Resident #100 documented showers for August 1, 2023 to August 22, 2023: a. 8/2/23 b. 8/9/23 c. 8/13/23 d. 8/16/23 2. 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 ensure chicken thawed properly to avoid potential hazards of contamination to other foods. The facility failed to ensure hygienic practices with serving and with the kitchen ice machine. The facility reported a census of 113. Findings include: On 08/21/23 at 09:45 AM during the initial tour of the facility kitchen with the Dietary Supervisor observation included a baking sheet pan of chicken thawing on a shelf in the refrigerator. The pan had red liquid from the thawing meat that surrounded the chicken. The shelf below the baking sheet of chicken had several bags of food including already cooked chicken and another packaged food. On 8/21/23 at 09:47 AM the dietary supervisor acknowledged the thawing meat should be on the lowest shelf to cooler to avoid possibility of the chicken blood dripping on other foods. On 08/21/23 at 09:55 PM observation in the kitchen with the Dietary Supervisor revealed the ice scoop lying inside the machine on top of the ice. On 8/21/23 at 9:56 AM the Dietary Supervisor…

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, record review, and policy review the facility failed to cover clean linen carts in the hallways to ensure that clean linen was kept free from contamination. The facility also failed to perform hand hygiene or change gloves while performing wound cares and wound dressing change and further failed to sanitize treatment scissors when soiled for 1 of 3 resident (Resident #96) wound cares observed. The facility reported a census of 113 residents. Findings include: 1. Observation of housekeeping staff passing clean linens revealed the following; On 08/21/23 from 11:58 AM to 12:15 PM with continuous observation of housekeeping staff passing personal laundry from a clean clothing cart in the 600 hallway, half of the clothing remained uncovered and open to debris as housekeeping staff went in and out of multiple residents rooms. The clean personal clothing cart observed uncovered with staff and residents present and moving through the hallway to and from the dining room. Observation on 08/23/23 at 13:03 PM of clean personal linen cart on the 400…

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 interview, resident interview, and clinical record review, the facility failed to treat residents with dignity and respect throughout cares provided for 2 of 7 residents reviewed. (Resident #76 and Resident #85).The facility reported a census of 113 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident#76 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. The MDS reflected Resident #76 diagnosis of Developmental disorder of speech and language, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and non-traumatic brain dysfunction. The MDS further documented Resident #76 required total dependence on staff for performing activities of daily living. On 8/23/23 at 09:43 AM Staff G, Certified Nursing Assistant (CNA) with 6 years of experience in the position, stated that on 8/1/23 she walked by the shower room, and overheard Staff E, CNA yell at Resident #76. She also reported that…

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 family interview the facility failed to post required notifications of ombudsman, survey agencies, and other support for advocacy. The facility also failed to provide accessibility of the survey results. The facility reported a census of 113. Findings Include: On 8/21/23 at 10:15 AM Family Member visiting requested information on how to contact state agencies. It was relayed the information is usually posted at the entrance or halls for easy access. The surveyor proceeded with family down two hallways to the front door and could not locate any signage other than a sign in a glass cabinet that noted This facility's survey results for the past three (3) years are available. The family member reported he did not know how to contact any state agencies and did not recall getting the information. On 8/22/23 at 9:50 AM the Administrator reported a tube with postings in his office and a framed copy of resident rights on the floor. The administrator indicated due to renovations and a plan for painting the hallway, signs were removed and being kept in…

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

Based on staff interview, record review, and facility policy review the facility failed to complete Beneficiary Notification forms for 2 of 3 residents reviewed for the implementation of Advanced Beneficiary Notification (ABN). Findings include: 1. Review of facility provided form titled SNF Beneficiary Protection Notification Review, signed on 08/11/23, for Resident #21 revealed there was no resident payment preference option selected in Section G: Options. 2. Review of facility provided form titled SNF Beneficiary Protection Notification Review, signed on 05/12/23, for Resident #12 revealed there was no resident payment preference option selected in Section G: Options. On 08/24/23 at 02:00 PM the facility Social Worker verified there was no option selected for Resident #21 and Resident #12 and confirmed an option selection is required for form completion. Review of facility policy titled Notice of Medicare Non-Coverage (NOMNC), with review/revision dated 02/14/23, revealed the expectation that the provider will issue the notice of non-coverage to appropriately inform beneficiaries…

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, resident interviews, and the facility policy review, the facility failed to maintain personal privacy and resident information confidential for 2 residents (Resident #76 and Resident #85) out of 7 reviewed. The facility reported a census of 113 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #76 dated 6/19/23 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. The MDS reflected Resident #76 diagnoses including Developmental disorder of speech and language, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and non-traumatic brain dysfunction. The MDS further documented Resident #76 required total dependence on staff for performing activities of daily living. On 8/23/23 at 1:10 PM Staff K, Certified Nursing Assistant (CNA) reported she had witnessed Staff E, CNA, use a personal cell phone while at work numerous times, including using social media TikTok live and FaceTime, then…

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, resident interviews, documentation reviews and the facility policy review, the facility failed to report alleged violations related to mistreatment of 2 residents (Resident #76 and Resident #85) out of 2 reviewed. The facility reported a census of 113 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident#76 dated 6/19/23 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. The MDS reflected Resident #76 diagnoses including Developmental disorder of speech and language, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and non-traumatic brain dysfunction. The MDS further documented Resident #76 required total dependence on staff for performing activities of daily living. On 8/23/23 at 09:43 AM Staff G, Certified Nursing Assistant (CNA) with 6 years of experience in the position, stated that on 8/1/23 while walking by the shower room, she overheard Staff E, CNA yelling at Resident #76. She later approached Staff F, CNA who gave a shower to Resident #76…

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, resident interview, and facility policy review, the facility failed to investigate an allegation of abuse to the State Survey Agency for 2 of 2 residents reviewed for abuse and neglect (Resident #76 and Resident #85). The facility reported a census of 113 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident#76 dated 6/19/23 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. The MDS reflected Resident #76 diagnosis of Developmental disorder of speech and language, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and non-traumatic brain dysfunction. The MDS further documented Resident #76 required total dependence on staff for performing activities of daily living. On 8/23/23 at 1:00 PM Staff J, Certified Nursing Assistant (CNA) reported that she made verbal reports to charge nurse and to Assistant of Director of Nursing (ADON) about witnessing mistreatment of Resident #76 and other residents by Staff E, CNA during cares. 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 record review, staff interviews, and policy review, the facility failed to develop and implement a comprehensive care plan for 3 of 30 residents reviewed (Resident #4, Resident #103, Resident #104). The facility reported a census of 113 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment for Resident #4, dated 7/9/23, documented diagnoses of non-Alzheimer's dementia, depression, and transient ischemic attack (TIA). The MDS identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Medication Administration Record (MAR) for August 2023 revealed Resident #4 took Donepezil HCL 10 mg once per day at bedtime for unspecified dementia and Duloxetine HCL 60 mg every morning and at bedtime for other specified depressive episodes. The MAR identified both medications started 7/3/23 on admission. The Comprehensive Care Plan (CCP) failed to address goals, desired outcomes, or resident preferences related to depression or dementia. The daily…

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, interviews, and policy review, the facility failed to properly update the Comprehensive Care Plan care for 3 of 30 residents (Resident #21, Resident #103, Resident #104) reviewed for care plan intervention effectiveness, review, and revision. The facility reported a census of 113 residents. Findings include: 1. The Minimum Data Sheet (MDS) assessment dated [DATE] for Resident #21 listed skin and ulcer/injury treatments that included pressure reducing devices for chair and bed, nutrition or hydration interventions, pressure ulcer/injury care, and application of nonsurgical dressings. Diagnoses included cancer and pain. The MDS identified a BIMS score of 11 which indicated moderate cognitive impairment. The Comprehensive Care Plan (CCP) for Resident #21, dated 6/30/23, documented a focus area of 'The resident has stage 4.' The goal documented the resident had a stage 4 that will be healed by review date 10/20/23. The CCP failed to include information specific to Resident #21'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 observations, interviews, and record reviews the facility failed to follow Physician's orders for ACE wraps daily application causing unrelieved swelling of lower extremities and discomfort for 1 of 30 sampled residents (Resident #19). The facility also failed to prime an insulin pen injection prior to administration and/or further failed to keep insulin pen in place after injection for the appropriate amount of time for 2 of 2 residents observed receiving insulin (Resident #86 and #103). The Facility reported a census of 113 residents. Findings include: 1. Review of the most recent Minimum Data Set (MDS) assessment (Admission) completed on 6/01/23 listed the following diagnoses for Resident #19: hip fracture, heart failure, atrial fibrillation, hypertension, cellulitis of right lower limb. The Brief Interview for Mental Status (BIMS) assessment most recently completed 5/31/23 revealed a score of 15 which indicated intact cognition. Review of the current Care Plan listed the focus area: impairment 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 observation, interviews, record review, and facility policy review the facility failed to implement interventions for blood glucose reading below 70 mg/dL (milligrams per deciliter) and for blood glucose readings above 400 mg/dL for 2 of 2 residents reviewed for unnecessary medications (Resident #63 and Resident #81). The facility census reported a census of 113. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated severe cognition impairment. The MDS revealed a diagnosis of diabetes mellitus (DM). The MDS revealed the resident received insulin injections 7 out of 7 days. The Care Plan dated 7/31/23 revealed a focus area of diabetic therapy. The interventions dated 1/21/21 revealed the resident's condition needed monitored based on clinical practice guidelines or clinical standards of practice related to the use of Lantus and Novolog. The Electronic Medical Record (EMR)…

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.

2. The Minimum Data Set (MDS) assessment for Resident #104, dated 7/10/23, documented diagnoses of sepsis, kidney failure, and diabetes with diabetic neuropathy. Section H of the MDS, titled Bladder and Bowel, documented an indwelling catheter. The Comprehensive Care Plan (CCP) dated 5/31/23 documented an indwelling catheter related to kidney failure with a goal to remain free from catheter related trauma through the review date of 9/19/23. Interventions included monitor for signs and symptoms of discomfort on urination and frequency and catheter care by CNA Q (every) shift and PRN. The Medication Administration Record (MAR) for August 2023 revealed the resident took ciprofloxacin HCl 500 mg twice a day for possible UTI/penile infection from 8/13/23 through 8/21/23. The Treatment Administration Record (TAR) for August 2023 documented a urinalysis on 8/13/23 and the foley catheter changed 8/13/23 for possible infection. Observation on 08/22/23 at 02:31 PM revealed Resident #104 propelled himself around the common area. His catheter bag rested in a dignity bag under his chair. 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 2. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident#96 had diagnoses including Diabetes Mellitus (DM) as an active diagnosis. MDS revealed the Brief Interview for Mental Status (BIMS) score to be 11, which indicated moderate cognitive impairment. The MDS revealed Resident #96 had one or more unstageable deep tissue injuries that were not present upon admission. MDS revealed that Resident #96 received pressure ulcer/injury care and the application of non-surgical dressings with or without topical medications. The Braden scale with lock date of 1/16/23, used to assess for the risk of pressure injury development, indicated the resident was at risk for pressure sores. The Care Plan documented the resident had potential for pressure ulcer development related to immobility with the initiated date of 2/17/23. The goal indicated that the resident will have intact skin free of redness, blisters or discoloration by/through review date. The Care Plan, revealed the focus area for 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.