Parkridge Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and policy review, the facilty failed to complete glove change and hand hygiene during personal cares, implement Enhanced Barrier Precautions (EBP) as indicated, and proper glucometer cleaning for 3 of 7 residents reviewed for infection control (Resident #8, #11, and #15). The facility reported a census of 86. Findings include:1. Resident #8's Minimum Data Set (MDS) completed on 3/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Diagnoses included Alzheimer's disease (progressive memory loss) and stroke (brain tissue damage). The MDS noted Resident #8 depended on staff for chair to bed transfers, bed mobility, personal hygiene, and toileting hygiene.On 5/12/26 at 12:45 PM observed Staff F, Hospice Certified Nursing Assistant (CNA), and Staff G, Hospice CNA, enter Resident #8's room to complete toileting cares and personal hygiene. Staff F and Staff G put gloves on, transferred Resident #8 from the wheelchair to…

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

Based on clinical record review, policy review, and staff interview, the facility failed to treat 1 of 7 residents (Resident #1) reviewed for dignity with respect by applying multiple incontinent briefs during personal hygiene care. The facility reported a census of 38 residents. Findings included: The 11/21/25 Minimum Data Set(MDS) assessment tool, listed diagnoses for Resident #1 which included sepsis(an infection of the blood), weakness, the need for assistance with personal care. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The MDS stated the resident was dependent on staff for toileting hygiene and toilet transfers. The facility policy Dignity, revised February 2021, stated the facility would care for residents in a manner that promoted and enhanced a sense of well-being, level of satisfaction with life , and feelings of self-worth and self-esteem. 8/25/25 Care Plan entries stated the resident required the assistance of 2 staff for toilet transfers. The entries stated the resident had urinary…

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 interview, the facility failed to carry out assessments for 1 of 3 residents reviewed for a change in condition(Resident #1) by failing to carry out timely skin assessments after a hospitalization. The facility reported a census of 38 residents. Findings included:The 11/21/25 Minimum Data Set(MDS) assessment tool, listed diagnoses for Resident #1 which included sepsis(an infection of the blood), weakness, and the need for assistance with personal care. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, stated the nursing staff would examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. A 9/8/25 Care Plan entry directed staff to monitor and document location, size, and treatment of skin injuries and to report abnormalities. 11/18/25 Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, observations, staff interview, and policy review, the facility failed to ensure food served and prepared in accordance with professional standards for food service safety. The facility reported a census of 88.Findings include: Review of August 2025 food temperature logs noted the following: 1.No breakfast temperature documentation for 21 days out of 31 2.No lunch temperature documentation for 21 days out of 31 3.No supper temperature documentation for 10 days out of 31Review of September food temperature logs noted the following: 1.No breakfast temperature documentation for 9 days out of 30 2.No lunch temperature documentation for 11 days out of 30 3.No supper temperature documentation for 21 days out of 30During a continuous lunch service observation on 10/1/25 at 11:45 AM, the following noted 1.An electrical extension cord wrapped to a bar on the service table noted with visible dried food splatter and grime 2.Top of cabinets, which were located above a food prep area, noted with 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 clinical record review, policy review, and staff and resident interviews, staff failed to transfer a resident using a technique which would not place pressure on the resident's compromised left foot and failed to notify the podiatrist in a timely manner of an open area for 1 of 3 residents reviewed for skin ulcers(Resident #6). The facility reported a census of 88 residents.Findings included: The Minimum Data Set(MDS) assessment tool, dated 8/20/25, listed diagnoses for Resident #6 which included osteomyelitis(infection of the bone) of the foot, diabetes, and heart failure. The MDS stated the resident required substantial to maximal assistance with chair to bed transfers and listed her Brief Interview for Mental Status(BIMS) score as 3 out of 15, indicating severely impaired cognition. The facility policy Wound Care, revised October 2010, stated the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The policy directed staff to review the resident's care plan to assess for any special needs of the resident.A 4/15/25 Foot and 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 electronic health record (EHR) review, observations, resident and staff interviews, the facility failed to ensure residents were aware of and offered alternative menu options for 2 of 3 residents reviewed for food (Residents #4 and #79). The facility reported a census of 88.Findings include: 1. The Minimum Data Set (MDS) Assessment, completed 7/29/25, revealed Resident #4 with a Brief Interview for Metal Status (BIMS) score of 12, indicating moderately impaired cognitive status. Diagnoses include chronic obstructive pulmonary disease (COPD), chronic pain, diabetes, hemiplegia/hemiparesis, malnutrition, and peripheral vascular/arterial disease. The MDS indicated Resident #4 with a physician-prescribed weight loss regimen which resulted in a significant weight loss within the past six months. The Care Plan revised on 8/6/25 indicated Resident #4 at risk for altered nutrition status related to diabetes, COPD, and advanced age. The Care Plan noted the presence of right above the knee amputation surgical incision with dehiscence and the decision for palliative care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a document of call light start and end time, resident interview, staff interview, and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time for 4 of 4 residents. (#2, #5, #8 and #11) The facility reported a census of 84 residents. Findings include: 1 The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview of Mental Status (BIMS) of 13 indicating no cognitive impairment and has the ability to be understood and understands others. The MDS documented diagnosis of diabetes mellitus, hemiplegia (muscle weakness or partial paralysis on one side of the body that affect the arms legs, and facial muscles) and macular degeneration (an eye disease that can blur your central vision) and required dependence with personal hygiene, transfer and toileting and always incontinent of bladder and bowel. On 6/25/25 at 11:40 a.m., Resident #2 stated that she can read the clock on the wall. Resident #2 stated that it takes…

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, clinical record review, resident and staff interview, facility policy review, the facility failed to follow the comprehensive Care Plan for 1 of 3 (Resident #2) reviewed for care plans. The facility reported a census of 84 residents. Findings include: The Quarterly Minimum Data Set (MDS) of Resident #2, dated 6/18/25, coded the resident dependent on assistance for personal hygiene, transfers and bed mobility. The MDS documented diagnoses that included diabetes mellitus, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms legs, and facial muscles) and macular degeneration (damage to the eyes retina, causing loss of vision). The Care Plan of Resident #2, revision date 1/2/25, identified a focus area of the Resident will continue to participate during my activities of daily living (ADL) as my condition allows. The Care Plan directed the staff she required 2 staff to assist me with cares, and 2 assist with bed mobility and 2 assist with upper and lower body dressing. Observation on 6/25/25 at 11:40 a.m., with 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, staff interview and policy review, the facility failed to provide incontinence care appropriately to prevent cross contamination for 1 of 3 residents observed for incontinence care (Resident #3). The facility reported a census of 84 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had short and long term memory problems, severely impaired for decision making abilities, required substantial to maximal staff assistance for all aspects of daily living and incontinent of bowel. The MDS revealed diagnosis of quadriplegia (a condition characterized by paralysis in all four limbs (arms and legs). The Care Plan of Resident #3, revision date 8/16/24, identified a focus area of the Resident not experience any skin conditions from incontinence. The Care Plan directed the staff to assist me with perineal cleansing as needed and observe my skin daily for irritation and redness. Observation on 6/25/25 at 11:15 a.m., Staff K, Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to notify the Physician and family when a resident experienced a change in condition for 1 of 3 residents reviewed (Residents #1). The facility reported a census of 75 residents. Findings include: The Clinical Census revealed Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 1/27/25. Resident #1 did not have a Minimum Data Set (MDS) completed due to new admission to the facility. A Progress Note titled BIMS evaluation (Brief Interview for Mental Status) dated 1/24/25 identified a score of 8, which indicated moderately impaired cognition. Review of the Clinical Record revealed Resident #1 had diagnoses of delirium, altered mental status, muscle weakness, anxiety disorder, pleural effusion, acute kidney failure, asthma, atrial fibrillation and a stroke affecting the left side. Review of Bowel Elimination form for Resident #1 revealed two large loose/diarrhea stools on 1/25/25 and 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.

Based on clinical record review, staff interview, facility investigation review and policy review the facility failed to report an allegation of abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 75 residents. Findings include: An Incident Report (IR) dated 1/8/25 at 3:30 PM documented Resident #2 was arguing with Resident #3 over who was going to marry the medication aide in that hallway. When the staff member entered the room, she observed Resident #2 standing over the bed of Resident #3 and Resident #3 reported Resident #2 had hit him on his right arm. Resident #2 confessed to hitting Resident #3. The report documented that both residents were separated. Review of document titled Intake Information revealed the facility filed an allegation for abuse related to a Resident to Resident Altercation for Resident #2 and Resident #3 on 1/9/25 at 12:06 AM. On 2/3/25 at 8:59 AM, the Administrator acknowledged and verified the incident occurred on 1/8/25 at 3:30 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 3 residents reviewed (Residents #2). The facility failed to implement physician orders in a timely manner. The facility reported a census of 75 residents. Findings include: Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, and hyperlipidemia. An Email Correspondence received by the DON (Director of Nursing) from the facility Advanced Registered Nurse Practitioner (ARNP) on 1/14/25 at 7:05 PM documented the following new Physician orders for Resident #1: -Increase Jardiance (diabetic medication) from 10 MG (milligrams) to 25 MG daily -Increase Insulin Glargine bedtime dose to 28 units subcutaneous -Start Cimetidine (medication used to decrease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 2 of 3 residents reviewed (Resident #1 and #2). The facility failed to complete and document nursing assessments related to nausea, vomiting and diarrhea for Resident #1. The facility also failed to complete vital signs with neurological assessments and complete a range of motion (ROM) assessment after a fall for Resident #1. The facility also failed to complete and document nursing assessments related diuretic usage for fluid overload and assess/monitor the efficacy and side effects of new medications started for fluid overload, sexual inhibition, anxiety and depression for Resident #2. The facility reported a census of 35 residents. Findings include: 1. The Clinical Census revealed Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 1/27/25.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, family interviews, hospital record review and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents reviewed (Resident #1) for falls. Resident #1 was identified as a fall risk prior and upon admission and interventions to prevent falls were not implemented upon admission to the facility. Resident #1 fell two times on the same day within 48 hours of admission. Based on staff interviews and documentation the staff did not provide appropriate level of assistance with transfers and the facility failed to complete a thorough assessment including vital signs and range of motion (ROM) after a fall occurred. The facility reported a census of 75 residents. Findings include: The Clinical Census revealed Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 1/27/25. Resident #1 did not have a Minimum Data Set (MDS) completed due to new admission to the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to maintain essential kitchen equipment. The facility reported a census of 87 residents. Findings include: On 8/25/24 at 8:50 AM, an initial kitchen observation revealed the following findings. a) Three (3) clear, plastic containers with brown flakes, different colored rings, and opaque rice shaped objects b) A previously opened, undated bag of shredded cheese c) Opened bottle of apple cider and regular vinegar stored on a rack shelf with Worcestershire Sauce and Hickory Smoke sauce bottles for resident consumption d) A previously opened, undated and unlabeled bag of light brow, disc shaped items. e) Empty food packages stored on a rack with dry goods f) A white, unlabeled storage bin containing white powder and a scoop inside. g) A previously opened clear, blue undated and unlabeled plastic bag containing a light pink substance stored on a pan in the…

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

Based on clinical record review, staff interview, guidance from the Resident Assessment Instrument (RAI) manual, and facility policy review, the facility failed to complete a quarterly assessment for 1 of 18 (Res #73) residents reviewed. The facility reported a census of 87 residents. Findings include: The admission Minimum Data Set (MDS) of Resident #73 documented an Assessment Reference Date of 4/19/24, with the most recent admission date of 4/15/2024. The MDS documented that the resident came from a hospital stay. The MDS Section of the Electronic Health Record of Resident #73, reviewed 8/26/24 at 3:32 pm, documented no MDS had been completed since his admission MDS of 4/19/24. The October 2023 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual directed a quarterly assessment must be completed 92 days from the prior MDS assessment Assessment Reference Date. On 8/26/24 at 4:05 pm, Staff A, LPN, MDS Coordinator stated she had opened a quarterly assessment and it would be completed by the end of the day. On 8/28/24 at 9:18 am, the Regional Director 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 observation, staff interview, and facility document review, the facility failed to administer medication in a timely manner for 1 of 18 residents reviewed (Resident #50). The facility reported a census of 87. Findings Include: 1. The Minimum Data Set (MDS) of Resident #50, dated 6/3/24, documented the resident had a Brief Interview of Mental Status (BIMS) identified the presence of short and long-term memory impairment. The MDS documented that the resident had short-term, and long-term memory loss. The MDS documented diagnoses that included: renal insufficiency, hypertension, aphasia, quadriplegia, seizure disorder, anxiety disorder, depression, and respiratory failure. It further documented her gastrostomy status, muscle contractures, and dysphagia. The Medication Administration Record (MAR) of Resident #50 for the month of August, 2024, documented an order of Simethicone (medication for excess gas) oral tablet 80mg, and Levetiracetam (anti-seizure medication) oral solution 5ml, via Gastric Tube (G-Tube) two times a day, at 05:00 AM and 03:00 PM. During observation 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 review, staff interviews, and policy review, the facility failed to provide routine scheduled baths for 1 of 21 residents reviewed (Resident #35). The facility reported a census of 87 residents. Findings include: On 8/25/22024 at 11:32 AM, Resident #35 admitted she had received two baths since she was admitted to the facility. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart failure, hypertension, Diabetes Mellitus, cardiogenic shock (lack of blood and oxygen to organs caused by heart failure), prosthetic heart valve, and shortness of breath. It indicated the resident required set-up assistance with eating and oral hygiene, moderate assistance with toileting, bathing, upper body dressing and personal hygiene, and maximal assistance with lower body dressing and footwear. The Electronic Health Record (EHR) Activities of 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 clinical record review, staff interview and resident interview, the facility failed to follow physician orders to obtain a resident's daily weight and twice daily oxygen saturation for 1 of 21 (#35) reviewed. The facility reported a census of 87 residents. Findings Include: On 8/25/24 at 11:42 AM, the resident was observed with bilateral, swollen ankles. The resident stated she had heart problems. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart failure, hypertension, Diabetes Mellitus, cardiogenic shock (lack of blood and oxygen to organs caused by heart failure), prosthetic heart valve, and shortness of breath. It indicated the resident required set-up assistance with eating and oral hygiene, moderate assistance with toileting, bathing, upper body dressing and personal hygiene, and maximal assistance with lower body dressing and footwear. It…

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 direct observation, staff interview, record and policy review, the facility failed to perform a gastric tube (G-Tube) feeding in a manner that protects residents from cross-contamination for 2 of 3 residents reviewed (Resident #24, #50). In addition, the facility failed to serve meals in a manner that protects residents from cross-contamination. The facility reported a census of 87. Findings include: 1. The Minimum Data Set (MDS) for Resident #50, dated 06/03/24, documented the resident had a brief interview for mental status (BIMS) score of 99, indicating the resident was incapable of completing a BIMS interview. It documented relevant diagnoses of renal insufficiency, hypertension, aphasia, quadriplegia, seizure disorder, anxiety disorder, depression, respiratory failure. It further documented her gastrostomy status, muscle contractures, and dysphagia. A continuous direct observation of the gastric tube (G-tube) feeding process on 8/26/24 starting at 3:07 PM and ending at 3:57 PM, revealed that Staff E, Licensed Practical Nurse, performed G-tube cares with soiled gloves…

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 and staff interviews, and facility policy review, the facility failed to prevent a male resident (Resident #1) from inappropriately kissing a female resident (Resident #2). The facility reported a census of 81 residents. Finding include: 1. The Quarterly Minimum Date Set (MDS) with an assessment date 5/15/24, documented Resident#1 had diagnoses which include, heart failure, Non-Alzheimer's Dementia, depression, insomnia and alcohol abuse. The MDS documented Resident #1 with adequate hearing and was able to be understood and understand others. The Brief Interview for Mental Status (BINS) documented a score of 13 which indicated no cognitive impairments and that the resident was independent with ambulation in the facility. The Plan of Care with an imitated date of 6/7/24, had a problem identified as follows; I display inappropriate/disruptive behaviors while in the dining room at meal times, and on 6/21/24, due to my inappropriate interaction with a female…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, the facility failed to supervise a male resident (Resident #1) with known sexual behaviors from inappropriately kissing a female resident (Resident #2). The facility reported a census of 81 residents. Finding include: 1. The Minimum Date Set (MDS) with an assessment date 5/15/24, documented Resident #1 with diagnosis for which include, heart failure, Non-Alzheimer's Dementia, depression, insomnia and alcohol abuse. The MDS documented Resident #1 with adequate hearing and was able to be understood and understands others. The Brief Interview for Mental Status (BINS) documented a score of 13 for which indicated no cognitive impairments and that the resident was independent in ambulation in the facility. The Plan of Care with an imitated date of 6/7/24, had a problem identified that, I display inappropriate/disruptive behaviors while in the dining room at meal times, and on 6/21/24, due to my inappropriate interaction with a female resident, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, policy review, document review, and staff interviews, the facility failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to evaluate where hazardous conditions may occur in the water systems and implement measures to prevent waterborne pathogens for 1 of 78 residents. Need universe The facility reported a census of 78 residents. Findings include: The Infection Prevention and Control Program policy, revised October 2018, states an Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of Resident #80's Care Plan, initiated 12/20/23, indicated the resident was treated for Legionnaires' Disease related to Legionella bacteria. Staff…

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

Based on resident interviews, call light log review, and facility policy review, the facility failed to answer the residents' call light in less than 15 minutes for 25% of the reviewed time period. The facility reported a census 78 residents. Findings include: On 2/19/24 at 10:12 am, Resident #39 reported she has waited up to an hour to receive cares when ringing her call light. On 2/19/24 at 10:16 am, Resident #22 reported call light times can be half an hour long. On 2/19/23 at 11:29 am, Resident #45 reported call light response time varies but it can be half an hour wait when staff is busy. A Call Light Report was requested for 5 rooms, which housed 9 patients, for a 4 day time period from 2/7/24 - 2/10/24. There were 59 call lights on the call log. Of the 59 calls, 15 of them took 18 minutes or longer to be answered, equaling 25% of the reviewed call lights. The longest call light time was documented as being turned on at 7:55 pm and not being answered until 9:50 pm, one hour and 55 minutes later. The facility document Answering the Call Light, revision date March 2021…

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 provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 78. Findings include: On 2/21/24 at 7:40 AM, Staff E, Cook, began serving breakfast to dining room residents. At the beginning of meal service, the temperatures of the foods were as follows: a) Pureed eggs - 190° b) Pureed toast - 209° c) Scrambled eggs - 170° d) Fried eggs - 167° e) Cream of Wheat - 190° At 7:49 AM, the first resident room tray, Tray #1, was plated and placed on the top shelf of a transport rack. At 7:59 AM, the last resident room tray was placed on the transport rack. At 8:00 AM, Staff E rechecked the fried egg temperature on Tray #1 and noted it was 109°. The tray was sent to the resident. At 8:07 AM, Staff F, Cook, rechecked a separate resident's milk temperature on another transport rack and noted it was 43.7°. The milk was replaced and the tray was sent to the resident's room. At 8:25 AM, the pureed and scrambled eggs' temperatures were taken and were 122° and 123.3°,…

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, resident and staff interview, and policy review, the facility failed to provide alternative food options for residents who refuse the food served. The facility reported a census of 78. Findings include: On 2/19/24 at 10:45 AM, Resident #48 stated there were no food choices for residents who didn't like what was being served. An observation at 6:25 AM revealed the menu did not have an alternative breakfast option for the week. On 2/21/24 at 6:37 AM, Staff G, Cook, stated there were no alternative options for breakfast. On 2/22/24 at 1:30 PM, the Dietary Manager (DM) stated the breakfast menu normally did not include an alternate but residents could request something different and it would be prepared. She stated the residents most likely had not been officially informed of that. On 2/26/24 at 8:00 AM, the Administrator stated residents are always welcome to request alternatives for all meals. A policy titled Resident Food Preferences and revised 7/2017 indicated if the resident refuses or is unhappy with his or her diet, the staff will create a care plan 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 resident and staff interviews, facility record review, and the facilities admission Agreement, the facility failed to exercise reasonable care for the protection of the personal property against one resident (Resident #15). The facility also failed to maintain proper maintenance to resident rooms to promote a homelike environment. The facility reported a census of 78 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) of Resident #15, dated 11/18/23, identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. On 2/19/24 at 11:09 am, Resident #15 reported during a room change a few months prior, a personal blanket was lost and was never found. She stated the blanket was hand made for her by her daughter and it was labeled with her name. She stated it was her cancer blanket. On 2/20/24 at 10:45 am, the laundry room was toured and the blanket was looked for in the lost and found area. Staff D, Laundry Supervisor reported she was aware of the missing blanket and had looked for it before but it had not been found.…

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, staff interviews, and policy review, the facility failed to implement a comprehensive Care Plan for 1 of 5 residents reviewed (#58). The facility reported a census of 78 residents. Findings include: 1. On 2/19/24 at 12:07 PM, Resident #58 was observed struggling to drink a glass of liquid in the dining room. On 2/19/24 at 1:55 PM, Resident #58's relative stated the resident had a functional ability decline. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 had diagnoses of Cerebral Infarction (blocked blood supply to the brain), hemiplegia affecting the left nondominant side, lack of coordination, slurred speech, and difficulty walking. The MDS did not identify a Brief Interview of Mental Status (BIMS) score, but the quarterly MDS dated [DATE] identified his BIMS score of 11 out of 15, indicating moderately impaired cognition. The MDS also indicated the resident was a set-up assist with eating and oral and personal hygiene but was dependent 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 observation, record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive care plan for 2 of 5 residents reviewed (#34 & #58). The facility reported a census of 78. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #34 revealed a diagnoses of Atrial Fibrillation (A-Fib), Deep Vein Thrombosis (DVT), Arthritis, Gastroesophageal Reflux Disease (GERD), Diabetes mellitus, Trochanteric Bursitis - Left Hip with pain, Morbid Obesity, and the Brief Interview for Mental Status (BIMS) score of 10 which suggested a moderate cognitive impairment. The Care Plan dated 12/19/2023 for Resident #34 lacked documentation for oxygen therapy. During an observation on 2/19/24 at 11:14 AM, Resident #34 was in bed receiving 4 liters oxygen by nasal cannula with a water bubbler humidifier attached. During an observation on 2/20/24 at 10:41 AM, Resident #34 was in bed receiving 2.5 liters oxygen by nasal cannula with a water bubbler humidifier…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement physician's orders for 2 of 26 residents (Resident #34 & #80). The facility failed to document the physician order for oxygen therapy for Resident #34 and later titrated oxygen without a physician's order. The facility reported a census of 78. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #34 revealed a diagnoses of Atrial Fibrillation (A-Fib), Deep Vein Thrombosis (DVT), Arthritis, Gastroesophageal Reflux Disease (GERD), Diabetes mellitus, Trochanteric Bursitis - Left Hip with pain, Morbid Obesity, and the Brief Interview for Mental Status (BIMS) score of 10 which suggested a moderate cognitive impairment. The Care Plan dated 12/19/2023 for Resident #34 lacked documentation for oxygen therapy. During an observation on 2/19/24 at 11:14 AM, Resident #34 was in bed receiving 4 liters oxygen by nasal cannula with a water bubbler humidifier attached. During an observation on 2/20/24 at 10:41 AM, 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 observations, resident and staff interview, and record review, the facility failed to provide restorative activities in order to maintain a functional range of motion and prevent a decline in activities of daily living for 2 of 2 residents (#48 and #58). The facility reported a census of 78 residents. Findings include: 1. On 2/19/24 at 12:07 PM, Resident #58 was observed struggling to drink a glass of liquid in the dining room. On 2/19/24 at 1:55 PM, Resident #58's relative stated the resident had a functional ability decline. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 had diagnoses of Cerebral Infarction (blocked blood supply to the brain), hemiplegia affecting the left nondominant side, lack of coordination, slurred speech, and difficulty walking. The MDS did not identify a Brief Interview of Mental Status (BIMS) score, but the quarterly MDS dated [DATE] identified his BIMS of 11 out of 15, indicating moderately impaired cognition. The MDS also indicated the resident was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, the facility failed to ensure call lights were responded to in a timely manner at no greater than 15 minutes for 5 of 5 residents reviewed (Residents #6, #7, #8, #9 and #10). The facility reported census was 82. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 5/31/23, Resident #6 had a Brief Mental Status (BIMS) score of 13 out of 15 indicating an intact cognitive status. Resident #6 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #6's diagnosis included congestive heart failure, diabetes mellitus and chronic obstructive pulmonary disease. During a continuous observation on 8/23/23 at 5:40 p.m. noted call light had been activated. At 6:02 p.m. observed call light remained activated. Entered Resident #6's room and inquired what he needed. Resident #6 stated he needed some fresh ice water and his urinal emptied. At 6:18 p.m., 38 minutes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews the facility failed to maintain a clean and comfortable environment for their residents. The facility reported census as 82 residents. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 6/14/23, Resident #8 had a Brief Mental Status (BIMS) score of 12 out of 15 indicating a mildly impaired status. Resident #8 was independent with transfers, mobility, toilet use and personal hygiene needs with limited assistance with toilet use. Resident #8's diagnosis included congestive heart failure, diabetes mellitus and morbid obesity. In an observation and interview on 8/24/23 at 9:40 a.m. Resident #8 stated she had concerns with the housekeeping services. Resident #8 points towards her floor which was covered with various debris and spill stains. Resident #8 stated her floor had not been mopped for two weeks. Observation noted debris and spill stains on her floor and bedside table. The toilet bowl had visible feces and stain rings in it.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family interview, and provider interview the facility failed to ensure physician orders are followed in accordance with professional standards of practice for 2 of 4 residents reviewed (Resident #5 #11). The facility reported census was 82. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 6/5/23, Resident #5 had a Brief Mental Status (BIMS) score of 13 out of 15 indicating an intact cognitive status. Resident #5 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #5's diagnosis included congestive heart failure, diabetes mellitus, renal failure, respiratory failure, atrial fibrilation and chronic obstructive pulmonary disease. According to the Hospital Discharge summary dated [DATE], Resident #5's medication orders included Eliquis 5 milligrams to be given twice daily. The June 2023 Medication Administration Record (MAR) indicated the Eliquis 5 milligrams was transcribed in error 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 clinical record review, staff, family and resident interview, the facility failed to provide perineal cares of incontinent residents unable to carry out the activity independently for 2 of 3 residents reviewed (Resident #10, #11). The facility reported census was 82. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 5/2/23, Resident #10 had a Brief Mental Status (BIMS) score of 12 out of 15 indicating mildly impaired cognitive status. Resident #10 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #10's diagnosis included congestive heart failure, diabetes mellitus and chronic obstructive pulmonary disease. In an interview on 8/31/23 at 12:50 p.m Staff M, certified nurse aide, stated when she had came in this morning and went to room [ROOM NUMBER], Resident #10 was upset, stating he was left to lay in his own urine since 3:00 a.m. Resident #10 claimed to have activated his call light and no one came. Staff M…

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, climatologist review and staff interviews, the facility failed to ensure a resident accessing the courtyard was adequately supervised for 1 of 1 residents reviewed (Resident #1). The facility reported census was 82. Findings include: According to a Minimum Data Set (MDS) with a reference date of 6/29/23, Resident #1 had a Brief Mental Status (BIMS) score of 12 out of 15 indicating mildly impaired cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. The MDS documented the resident as independent with set up help for locomotion on and off the unit. Resident #1's diagnosis included multiple sclerosis, lupus and unspecified abdominal pain. The Care Plan revised on 9/14/22 documented Resident #1 required staff assist with her activities of daily living due to she is unable to transfer independently. The care plan directed staff that she used her wheelchair for mobility. The care plan lacked any interventions on locomotion, use of the court yard and if safe to be in 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.