Panora Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, policy review, and Resident Assessment Instrument (RAI) Manual, the facility failed to ensure proper Minimum Data Set (MDS) coding for three of fifteen residents reviewed for MDS assessments by not coding resident's diagnoses when indicated, and improperly coded medication and tobacco use (Resident #1, #3, and #4). The facility reported a census of 38 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had diagnoses of chronic obstructive pulmonary disease (COPD). The MDS failed to indicate the resident had a multi-drug resistant organism (MDRO). The Care Plan initiated 12/18/24 revealed the resident had a risk for potential infection related to a MDRO. The Care Plan directed staff to assess for signs and symptoms of infection, administer antibiotics per the physician orders, and use enhanced barrier precautions (EBP) when performing high-contact care activities. The Treatment Administration Record dated 12/1/25…

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, electronic health record (EHR) review, staff interview, and policy review, the facility failed to complete an admission smoking evaluation for 1 of 2 residents reviewed for smoking (Resident #1). The facility reported a census of 38. Findings include: The EHR census tab for Resident #1 showed the current admission date of 12/5/25. Resident #1 had previously been admitted from 2/5/25 to 3/11/25.The Minimum Data Set (MDS) assessment completed on 12/8/25 revealed Resident #1 with a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Diagnoses included a recent pneumonia diagnosis, dyspnea (shortness of breath), anxiety, bipolar disorder, and depression. Resident #1 noted to use a manual wheelchair independently but requiring staff assistance for transfers. The MDS indicated the use of tobacco products.The Care Plan, last updated 12/26/25, documented Resident #1 smokes. Interventions included completing a Smoking Evaluation on admission and as needed. During an observation on 12/31/25 at 8:00 AM, Resident #1 seen smoking a…

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

Based on observations, electronic record review, staff interviews, and policy review, the facility failed to follow infection control practices to prevent cross contamination by not completing hand hygiene and glove change during resident cares (Resident #15). The facility reported a census of 38. Findings include: The Minimum Data Set (MDS) Assessment completed on 11/13/25 revealed Resident #15 with Brief Interview for Metal Status score of 15, indicating intact cognition. Diagnoses include multidrug-resistant organism, neurogenic bladder (nerve damage causing poor bladder control), and paraplegia. The MDS indicated the presence of a urinary catheter. The Care Plan, last updated 11/26/25, included a focus area related to the risk of infection due to the presence of a drug-resistant microorganism. Interventions included the use of enhanced barrier precautions (EBP) when performing high-contact care activities. EBP included the use of gowns and gloves. During an observation on 12/29/25 at 4:00 PM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, completed catheter and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review the facility failed to review and revise the Care Plan for 3 of 4 residents reviewed (Resident #1, Resident #3, Resident #4). The facility failed to revise the Care Plan to include recommendations from the PASRR Level II (Resident #1, Resident #3, Resident #4). The facility reported a census of 35 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had an unscorable Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment. The document revealed diagnoses of diabetes mellitus, anxiety, depression, schizophrenia, Post Traumatic Stress Disorder (PTSD), drug induced akathasia, and insomnia. The document disclosed the resident took antianxiety and antidepressant medications. The facility provided document, Preadmission Screening and Resident Resident Review (PASRR) Level II Outcome dated 3/9/25 identified Resident #1 had a time limited approval beginning on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review the facility failed to identify and document target behaviors and/or side effects of medications prescribed to promote or maintain a resident's highest practical mental and psychosocial well-being for 4 of 4 residents reviewed (Resident #1, Resident #2, Resident #3, Resident #4). The facility failed to identify the target behaviors and/or the side effects of medications on either the Electronic Medical Administration Record (EMAR) or the Care Plan. The facility reported a census of 35 residents. 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had an unscorable Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment. The document revealed diagnoses of diabetes mellitus, anxiety, depression, schizophrenia, Post Traumatic Stress Disorder (PTSD), drug induced akathasia, and insomnia. The document disclosed the resident took antianxiety and antidepressant medications. Resident #1's…

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

Based on observation, resident and staff interviews, staff schedules, and facility assessment review, the facility staff failed to ensure sufficient nursing staff present during scheduled shifts and to ensure call lights were consistently answered within a reasonable amount of time, within 15 minutes, for 5 of 5 nursing halls. The facility reported a census of 40 residents. Findings include: 1. During a continuous observation on 1/14/25 starting at 8:50 AM and ending at 9:40 AM on the 100 and 300 nursing halls, a total of 6 call lights were observed. Breakfast was served in the dining room during this time. Call lights were primarily addressed by one Certified Nursing Assistant (CNA). Two CNA were helping residents during the meal. One was a CNA from the 400 hallway and the other was the Restorative Aide. By the end of the observation period, 1 call light remained unanswered which had been on since 9:20 AM. During confidential resident interviews starting on 1/12/25 at 11:00 AM, 6 of 11 interviewable residents reported prolonged responses to call lights and receiving the requested…

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, observations, staff interview, and policy review, the facility failed to provide peri-care in a manner to prevent cross-contamination and infection for one of three residents observed for peri-care. The facility also failed to ensure staff changed gloves and sanitized hands in accordance with proper infection control techniques when contaminated to protect against cross contamination and potential infection for four of twelve residents observed in the sample. The staff failed to utilize a barrier when emptied one of two catheters observed for catheter care, and failed to remove personal protective equipment prior to exit from an enhanced barrier precautions room for one of five halls observed. The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses of a pressure ulcer and osteomyelitis (a bone infection and inflammation) to the sacrum and coccyx, neurogenic bladder, and multidrug resistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview and policy review the facility failed to ensure staff transferred a resident safely and utilized a gait belt for one of three residents reviewed for transfers (Resident #39). The facility reported a census of 40 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had diagnoses of Parkinson's Disease, diabetes, and dementia. The MDS revealed the resident had a Brief Interview for Mental Status score of 10 which indicated moderately impaired cognition. The resident required partial to moderate assistance for transfers, The Care Plan initiated 12/26/24 revealed the resident had poor safety awareness related to cognition and had a risk for falls. The resident required assistance with activities of daily living (ADL's). The Care Plan directed staff to provide assistance of one for bed mobility and transfers. The Progress Notes revealed the following: a. On 1/8/25 at 4:00 AM revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident interviews, staff interviews and policy review, the facility failed to keep all areas clean in the facility and in good repair. The facility reported a census of 36 residents. Findings include: Observations during the dates of 4/9/24 and 4/10/24 revealed the following: 1. On 4/9/24 at 9:00 AM, the bathroom in room [ROOM NUMBER] observed to have fecal matter on the rim of the toilet bowl and inside the toilet bowl. What appeared to be fecal matter observed on the wall in the bathroom and on the floor, next to the floor trim. Observed rust around the toilet rim on the floor. The toilet had a bar attached under the toilet seat with handles. The bar covered in rust, leaving rust stains on the rim of the toilet under the bar. 2. On 4/9/24 at 9:27 AM, a section of the lower wall by the shower room in the 100 hallway had wallpaper peeling and the plaster coming off by the floor board. The section of wall loose, and when touched would move several inches inward. 3.…

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, staff failed to prepare and serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 36 residents. Findings include: 1. On 4/10/24 at 11:40 AM, during continuous observation of the lunch service, Staff A, [NAME] placed the serving utensils of scoops and tongs, for service of the food, on the counter attached to the front of the steam table. Staff A repeatedly leaned over to scoop food touching the front of her apron to the serving utensils and continued to use the same utensils to serve the food. Staff A applied gloves, opened the refrigerator with the gloved hand, with the same gloved hands touched a slice of cheese, placed the cheese on a plate, and proceeded to open a package of buns, remove a bun, placed bun on a plate and then placed slice of cheese on the bun. 2. On 4/10/24 with meal starting at 11:40 AM, Staff B, Kitchen Aide, scooped a piece of cake onto a plate sitting on the counter, leaned across to scoop another piece of cake…

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 interviews and policy review, the facility failed to perform appropriate infection prevention and control practices during medication administration, including hand hygiene. The facility reported a census of 36 residents. Findings include: During an observation for medication administration 4/10/24 at 11:01 AM, Staff C, RN, applied gloves, placed a wax barrier down on a resident's bedside table, placed alcohol wipes and then a blood glucose meter with a test strip and needle on the wax barrier in preparation to obtain a blood sugar reading for a resident. Staff C realized she forgot a cotton ball and returned to the medication cart to obtain a cotton ball, then using the same gloves inserted the needle to obtain blood, massaged the resident's finger to bring blood to the surface, and then inserted the test strip into the glucose meter and obtained blood on the test strip. The meter read an error. Staff C then took off her gloves and placed them on table, the gloves were not placed on the wax barrier, they were placed directly on the resident's bedside…

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 revise and update the Care Plan to include adequate interventions for a resident that was at high risk for elopement for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of schizophrenia, psychotic disorder, hypertension, and thyroid disorder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of the Progress Notes for Resident #6 showed documentation of exit seeking for the following dates: • 6/7/23 Resident exit seeked times two this shift. • 6/8/23 Resident attempted numerous times to exit several exits. • 6/17/23 Resident had been exit seeking off and on this evening and pacing in the hallways frequently this shift. • 6/22/23 Resident attempted to exit the building this morning by himself. • 6/23/23…

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