Stone Cottage Care Center

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to interact with a resident in a respectful manner for 1 of 3 residents reviewed for dignity(Resident #26). The facility reported a census of 30 residents.Findings:The Quarterly Minimum Data Set(MDS) assessment tool, dated 7/17/25, listed diagnoses for Resident #26 which included heart failure, diabetes, and hemiplegia(one-sided paralysis) and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/19/25, stated the resident had chronic obstructive pulmonary disease and directed staff to administer aerosol or bronchodilators(medications that treated breathing conditions) as ordered. On 9/4/25 at approximately 8:45 a.m., Staff A Certified Medication Assistant(CMA) provided the resident her Symbicort inhaler(a medication inhaled which helped with breathing conditions) and the resident inhaled 2 puffs. After this, Staff A provided the resident a glass of water and the resident swished her mouth and swallowed 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, clinical record review, policy review, and staff interivew, the facility failed to ensure a resident rinsed their mouth in accordance with professional standards for 1 of 1 residents reviewed for the administration of an inhaler(Resident #26). The faciltiy reported a census of 30 residents. Findings:The Quarterly Minimum Data Set(MDS) assessment tool, dated 7/17/25, listed diagnoses for Resident #26 which included heart failure, diabetes, and hemiplegia(one-sided paralysis)and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Provision of Physician Ordered Services, dated 12/23, stated the purpose of the policy was to provide physician ordered services according to professional standards of quality. The September 2025 Medication Administration Record(MAR) listed a 3/24/22 order for Symbicort Aerosol 160-4.5 micrograms[mcg] (budesonide-formoterol fumarate, an inhaler which treats lung conditions) 2 puffs twice daily. The MAR directed staff to ensure the resident rinsed their mouth 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 observation, clinical record review, policy review, and staff interview, the facility failed to notify the physician of a resident's refusal of an ordered diet and failed to carry out specialized Speech Therapy(ST) services for a diagnoses of dysphagia(difficulty swallowing) for 1 of 2 residents reviewed for a change in condition(Resident #10). The facility reported a census of 30 residents. Findings include:The Quarterly Minimum Data Set(MDS) assessment tool, dated 8/16/25, listed diagnoses for Resident #10 which included dysphagia(difficulty swallowing), Parkinson's disease(a disease which caused tremors and lack of mobility), and anxiety disorder. The MDS stated the resident had a mechanically altered diet and listed his Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Provision of Physician Ordered Services dated 12/23, stated the facility would provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. A 7/16/25 5:40 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interviews, staff interviews, and the facility policy, the facility failed to adequately supervise a resident after they went outside without oxygen for 1 of 1 residents reviewed for elopement (Resident #22). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The MDS indicated the resident utilized oxygen therapy. The Care plan revealed a focus area revised on 11/13/24 for a diagnosis of COPD and is at risk for shortness of breath, impaired breathing and respiratory infections and utilizes O2. The interventions dated 7/9/24 indicated to administer supplemental oxygen (02) as ordered per physician. The Care Plan revealed a focus area revised on 11/13/24 for impaired cognitive function and/or…

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 the facility policy, the facility failed to verify oxygen orders with the hospice provider for 1 of 1 residents reviewed oxygen therapy orders (Resident #22). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The MDS indicated resident utilized oxygen therapy. The Care plan revealed a focus area revised on 11/13/24 for a diagnosis of COPD and is at risk for shortness of breath, impaired breathing and respiratory infections and utilizes O2. The interventions dated 7/9/24 indicated to administer supplemental oxygen (02) as ordered per physician. The EMR revealed the following Physician Orders: a. ordered 4/8/25- Oxygen via nasal canula (n/c) 1-5L as needed (PRN) to keep 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, policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed 5%. The facility's medication error rate calculated as 7%. The facility reported a census of 30 residents.Findings include:The Annual Minimum Data Set(MDS) assessment tool, dated 7/10/25, listed diagnoses for Resident #8 which included anxiety, hemiplegia(paralysis affecting one side of the body), and paraplegia(paralysis affecting the lower body) and listed her Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. A Care Plan entry, revised 2/1/24, stated the resident was a smoker.The September 2025 Medication Administration Record(MAR) listed the following orders:a . 7/21/25 Famotidine(a medication used to reduce stomach acid) tablet 20 milligrams(mg) two times per day.b. 7/16/25 nicotine patch(assisted in nicotine cessation) 24 hour 14 mg/hour 1 patch one time a day. On 9/3/25 at 8:16 a.m., Staff A Certified Medication Assistant(CMA) administered Resident #8's morning medications. Staff 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 record review, staff interviews, and the facility policy, the facility failed to administer a resident their prescribed controlled medication for 1 of 6 residents reviewed for medication administration (Resident #17). The facility reported a census of 30 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored a 10 out of 15 on the Brief Interview for Mental Status, which indicated cognition moderately impaired. The MDS revealed diagnoses for anxiety disorder, bipolar disorder, and seizure disorder or epilepsy. The MDS indicated the resident prescribed antipsychotics, antianxiety, and antidepressant medications. The Care Plan revealed a focus area revised on 9/3/25 for use of antianxiety medications related to a seizure disorder. The interventions dated 9/3/25 directed staff to give the resident anti-anxiety medications as ordered by the physician.The EMR (Electronic Medical Record) revealed the following Physician Orders: a. Ativan Oral…

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 offer a Covid-19 booster to 1 of 5 residents reviewed for immunizations(Resident #3) and failed to provide information to staff regarding the Covid-19 vaccination. Findings included:1. The Annual Minimum Data Set(MDS) assessment tool, dated 6/19/25, listed diagnoses for Resident #3 which included hemiplegia(one-sided weakness), mild intellectual disabilities, and muscle weakness and listed her Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The resident's Iowa Health and Human Services vaccination list, stated the resident received a Covid-19 vaccination on 6/27/24. The facility lacked further documentation of education provided to the resident regarding an updated Covid-19 booster. 2. On 9/4/25 at approximately 11:00 a.m., Staff F Laundry Staff stated the facility did not provide information to her regarding Covid-19 vaccinations. On 9/4/25 approximately 1:00 p.m. Staff G Housekeeping staff stated the facility did not provide information to her…

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

Based on clinical record review, staff and resident interviews, the facility failed to ensure a resident's right of choice and self determination regarding their health care needs for 1 of 3 residents reviewed. (Resident #1) The facility reported census was 26. Findings include: According the Quarterly Minimum Data Set (MDS) with a reference date of 2/20/24, Resident #1 had a Brief Mental Status (BIMS) score of 11 which indicated a moderately impaired cognitive status. Resident #1 required maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 was coded as always incontinent of bladder and continent bowel. Resident #1's diagnosis included cerebrovascular accident (stroke), hemiplegia, renal insufficiency and seizure disorder. In an interview on 3/20/25 at 1:33 p.m Staff B, Certified Nurse Aide (CNA), stated she was working an overnight shift on 1/20/25. It was after 10:00 p.m. and she and Staff E, CNA, had just cleaned and prepared Resident #1 for bed and had exited his room when Staff A, Licensed Practical Nurse (LPN), approached…

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

Based on clinical record review, staff and family interview, the facility failed to ensure that the transfer or discharge met all documentation requirements necessary for a safe and effective transition of care for one of four residents reviewed. (Resident #1) The facility reported census was 25. Findings include: According to a Quarterly Minimum Data Set (MDS) with a reference date of 7/12/24, Resident #1 had short- and long-term memory deficits and severely impaired cognitive status for daily decision making. Resident #1 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 was always incontinent of bladder and was frequently incontinent of bowel. Resident #1's diagnosis included cerebrovascular accident (stroke), hemiplegia, chronic obstructive pulmonary disease. In an interview on 12/31/24 at 12:57 p.m. Staff B, Social Worker, stated the discharge process involving Resident #1 lasted 6 months. There was a facility located which seemed a better fit as they could provide a day program. Staff B stated…

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

Based on clinical record review, staff and family interview, the facility failed to provide adequate notice of discharge in writing and proper contents of notice, including a statement of the resident's appeal rights prior to discharge for one of four. (Resident #1) The facility reported census was 25. Findings include: According to a Quarterly Minimum Data Set (MDS) with a reference date of 7/12/24, Resident #1 had short- and long-term memory deficits and severely impaired cognitive status for daily decision making. Resident #1 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 was always incontinent of bladder and was frequently incontinent of bowel. Resident #1's diagnosis included cerebrovascular accident (stroke), hemiplegia, chronic obstructive pulmonary disease. In an interview on 12/31/24 at 12:57 p.m. Staff B, Social Worker, stated the discharge process involving Resident #1 lasted 6 months. There was a facility located which seemed a better fit as they could provide a day program. Staff B stated…

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 document review, policy review, and staff interviews, the facility failed to employ a qualified person to serve as the Director of Food and Nutrition Services in the absence of a full-time dietitian. The facility reported a census of 22 residents. Findings include: The facility policy Dietary Services Administration effective 3/2015, stated if a dietician was not employed full time, the facility would designate a person to serve as the Director of Food Service who received frequently scheduled consultations from a qualified dietician. The facility would designate a person to serve as the Food Services Director who was a qualified dietitian, a graduate of dietetic technician or dietetic assistant training program or, a graduate of a state-approved course that provided 90 or more hours of classroom instruction in food service supervision and who had experience as a Food Service Supervisor in a health care institution. On 9/23/24 at 9:29 a.m. the Dietary Manager stated she was not a Certified Dietary Manager (CDM), but stated she was in the course. She stated she could not…

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, policy review, and staff interview, the facility failed to maintain adequate sanitation for 2 of 2 kitchen observations and failed to carry out sanitary food handling during 1 of 1 meal service observation. The facility reported a census of 22 residents. Findings: The initial kitchen tour, conduced on 9/23/24 at 9:29 a.m., revealed the following concerns: a. Dust particles hung from the 3 spigots of the fire suppression system over the stove. An observation of the noon meal service on 9/24/24 at 11:30 a.m. revealed the following concerns: a. Dust remained on the spigots of the fire suppression systems. A long dust string extended from the bottom of one of the spigots to the horizontal fire suppression pipe. b. [NAME] splatters on the inside floor of the microwave with brown solid food debris on the inside of the door. Yellow and brown solid food debris was present on the front of the microwave near the door opener. The outside of the microwave was sticky to the touch. c. Thick dust…

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 employee file review, policy review and staff interviews, the facility failed to conduct a record check evaluation prior to employment to indicate clearance for work for 1 of 5 employee files reviewed. The facility reported a census of 22 residents. Findings include: The untitled facility staff roster listed a hire date for Staff B Registered Nurse(RN) as 9/11/23. An 8/30/23 Single Contact License and Background Check(SING) stated a Criminal History(CCH) record was found and the results would be faxed. The facility lacked further documentation regarding Staff B's CCH and lacked documentation of a record check evaluation completed to indicate she could work at the facility. On 9/25/24 at 2:22 p.m., the Business Office Manager(BOM) stated the facility could not locate the record check evaluation for Staff B and stated she thought they would receive a citation for this. She stated this should be completed prior to hire. On 9/25/24 at 3:30 p.m. the Administrator stated they initiated a background check for Staff B and she was off the schedule until Friday. She stated background…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to include fall interventions for 1 of 2 residents reviewed with a history of falls (Resident #21), failed to address nutrition needs for 1 of 2 residents reviewed for weight loss (Resident #21), and failed to address a resident's history of sexual behaviors toward other residents/staff for 1 of 2 residents reviewed for resident-to-resident interactions (Resident #12). The facility reported a census of 22 residents. Findings include: 1. The 5-Day Minimum Data Set (MDS) assessment tool, dated 7/17/24, listed Resident #21's admission date as 7/10/24 with the diagnoses of stroke, shortness of breath, and diabetes. The MDS stated the resident had a fall within the last month prior to admission and stated the resident required substantial/maximal assistance for chair transfers, toilet transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 9 out of 15, which indicated moderately impaired…

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 the facility policy, the facility failed to ensure an insulin vial discarded after it was opened past 28 days for 1 of 1 residents reviewed for insulin administration (Resident #5). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 revealed 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition intact. The MDS revealed a diagnosis of diabetes mellitus (DM). The MDS revealed the resident received insulin for 7 out of 7 days. The Care Plan revealed a focus area dated 12/13/24 for DM I/II and at risk for frequent infections, alternation of skin, visual impairment, hyper/hypoglycemia, renal failure and cognitive/physical impairments. The EMR (Electronic Medical Record) revealed a Medical Diagnosis for Type II DM without complications The EMR revealed the following Physician Orders: a. Lantus Subcutaneous Solution 100 units/ml (milliliters)-…

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 interviews, the facility failed to recognize and address weight fluctuations for a resident at risk of impaired nutrition for 1 of 2 residents reviewed for weight loss(Resident #21). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 7/17/24, listed diagnoses for Resident #21 which included stroke, shortness of breath, and diabetes and listed the resident's Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. The facility policy Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised September 2017, stated nursing staff would monitor and document weights of residents and would report significant weight loses to the physician. The staff and physician identified pertinent interventions based on identified causes. A 7/9/24 hospital Registered Dietician note stated the resident had inadequate energy intake due to a decreased ability to consume sufficient energy evidenced by weight loss and insufficient…

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, policy review, and staff and resident interviews, the facility failed to ensure a resident's oxygen tank was available for use for 1 of 1 residents reviewed receiving oxygen therapy (Resident #3). The facility reported a census of 22 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 6/27/24, listed diagnoses for Resident #3 which included chronic obstructive pulmonary disease (COPD, a disease of the lungs which caused shortness of breath and difficulty breathing), diabetes, and pain in an unspecified joint. The MDS stated the resident had shortness of breath with exertion (such as walking) and when lying flat. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 10 out of 15, which indicated moderately impaired cognition. The facility policy Oxygen Administration, revised October 2010, directed staff to set up oxygen for residents who received oxygen therapy. A 4/12/24 Order Details report listed an order for oxygen 1 liter as needed to keep oxygen greater than 90%. 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.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure that 1 of 1 resident reviewed for pain (Resident #15) received treatment and care related to pain management. The facility reported a census of 22 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 6/20/24, listed diagnoses for Resident #15 which included non-Alzheimer's dementia, diabetes, and hypertension. The MDS stated the resident had frequent pain over the last 5 days and listed the resident's Brief Interview for Mental Status (BIMS) score as 12 out of 15, which indicated moderately impaired cognition. The MDS documented that for the 5 day MDS look back period the resident did not receive any as needed (PRN) pain medication, or non-medication intervention for pain, only scheduled pain medication. The facility policy Pain Management revised 2015, stated pain management was an essential component of health care and directed staff to recognize when the resident was experiencing pain and manage or prevent pain. The policy directed…

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

Based on record review, staff interview, and facility policy review, the facility failed to screen residents for eligibility and/or failed to document refusals for the pneumococcal vaccines for 3 of 5 residents reviewed. (Resident #5, Resident #7, and Resident #12). The facility reported a census of 22 residents. Findings include: 1. The Review of Resident #5 EMR (Electronic Medical Record) Immunization Record revealed no documentation of the resident receiving a pneumococcal vaccine. The Review of Iowa Registry Immunization System (IRIS) revealed the resident received the pneumococcal 13-valent conjugate vaccine (PCV13) on 10/27/15. The facility lacked documentation the resident received/offered/declined any other pneumococcal vaccines. 2. The Review of Resident #7 EMR Immunization Record revealed the resident received PCV13 on 11/13/15. The Review of IRIS revealed the resident received the pneumococcal 23 vaccine on 9/2/14. The facility lacked documentation the resident offered/declined any additional pneumococcal vaccines. 3. The Review of Resident #12 EMR Immunization Record…

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

Based on record review, staff interview, and facility policy review the facility failed to screen residents for eligibility of the COVID-19 vaccines and/or failed to document refusal or acceptance of the COVID-19 vaccines for three of five residents reviewed. (Resident #5, Resident #7, and Resident #12) ) The facility reported a census of 22 residents. Findings include: 1. The Review of Resident #5 EMR (Electronic Medical Record) Immunization Record revealed the resident refused a COVID-19 vaccine (no date documented). The Review of Iowa Registry Immunization System (IRIS) revealed the resident received the Pfizer COVID-19 vaccine on 12/29/22. The facility lacked documentation the resident received/offered/declined any other COVID-19 vaccines. 2. The Review of Resident #7 EMR Immunization Record revealed the resident received Moderna COVID-19 booster on 10/11/23. The Review of IRIS revealed the resident received the Moderna COVID-19 on 10/11/23. The facility lacked documentation the resident offered/declined any additional COVID-19 vaccines. During an interview on 9/26/24 08:30 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.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to treat residents with dignity and respect by failing to assist a resident with positioning in a dignified manner (Resident #1), failing to avoid roughness during incontinence cares (Resident #5), failing to speak to residents in a dignified manner and ensure confidentiality (Resident #5), and failing to engage with residents during the provision of cares (Resident #9) for 3 of 11 residents reviewed for dignity. The facility reported a census of 23 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/18/24, listed diagnoses for Resident #1 which included severe intellectual disabilities, conduct disorder, and disruptive mood dysregulation disorder (a condition characterized by ongoing irritability, anger, and frequent, intense temper outbursts). The MDS documented the resident exhibited physical behavioral symptoms directed toward others such as hitting, kicking, pushing, and grabbing which occurred on 4-6 days during the 7 day…

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, policy review, and staff and resident interviews, the facility failed to protect a resident (Resident #4) from being pinched by another resident (Resident #1) on 4/17/24 with a history of physical aggression for 1 of 1 residents reviewed for abuse. The facility reported a census of 23 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/18/24, listed diagnoses for Resident #1 which included severe intellectual disabilities, conduct disorder, and disruptive mood dysregulation disorder (a condition characterized by ongoing irritability, anger, and frequent, intense temper outbursts). The MDS stated the resident exhibited physical behavioral symptoms directed toward others such as hitting, kicking, pushing, and grabbing which occurred on 4-6 days during the 7 day review period and listed her cognition as severely impaired. A 3/22/23 Incident Audit Report stated another resident (Resident #15) yelled ow stop and the resident (#1) swatted toward the resident. The staff member did not witness contact…

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, policy review, and staff and resident interviews, the facility failed to report an allegation of abuse to the State Agency when a staff member failed to treat a resident with dignity and respect during positioning (Resident #1) for 1 of 2 residents reviewed for an allegation of abuse. The facility reported a census of 23 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 4/18/24, listed diagnoses for Resident #1 which included severe intellectual disabilities, conduct disorder, and disruptive mood dysregulation disorder (a condition characterized by ongoing irritability, anger, and frequent, intense temper outbursts). The MDS stated the resident exhibited physical behavioral symptoms directed toward others such as hitting, kicking, pushing, and grabbing which occurred on 4-6 days during the 7-day review period and listed her cognition as severely impaired. A 3/28/23 Care Plan entry stated the resident was comforted by being on the floor and may position herself on the floor for comfort. An untitled 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.

Based on observation, clinical record review, policy review, and staff and resident interviews the facility failed to complete a thorough investigation and ensure immediate protection for 2 of 2 residents reviewed for an allegation of abuse (Resident #1) from a staff member and for an allegation of abuse from a fellow resident (Resident #3). The facility reported a census of 23 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 4/18/24, listed diagnoses for Resident #1 which included severe intellectual disabilities, conduct disorder, and disruptive mood dysregulation disorder (a condition characterized by ongoing irritability, anger, and frequent, intense temper outbursts). The MDS stated the resident exhibited physical behavioral symptoms directed toward others such as hitting, kicking, pushing, and grabbing which occurred on 4-6 days during the 7-day review period and listed her cognition as severely impaired. a. A 3/28/23 Care Plan entry stated the resident was comforted by being on the floor and may position herself on the floor for comfort. An…

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

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to adequately supervise a resident (Resident #3) in order to protect another resident's personal privacy (Resident #1) for 2 of 5 residents reviewed for supervision. The facility reported a census of 23 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 4/18/24, listed diagnoses for Resident #1 which included severe intellectual disabilities, conduct disorder, and disruptive mood dysregulation disorder (a condition characterized by ongoing irritability, anger, and frequent, intense temper outbursts). The MDS listed her cognition as severely impaired. The facility policy, Resident Rights, revised October 2022, stated residents had the right to privacy. A 12/5/23 Nurses Note stated the resident refused to keep clothes on. The Care Plan intervention dated 12/6/23 documented Resident #1 often disrobes and to allow her privacy to do so. A 12/19/23 Nurses Notes stated the resident refused staff assistance to put on a brief and pants. A 12/27/23…

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

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to provide sufficient staff with skill sets to care for a cognitively impaired resident who required 1:1 supervision (Resident #1) and a resident with behaviors affecting others (Resident #3). The facility reported a census of 23 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 4/18/24, listed diagnoses for Resident #1 which included severe intellectual disabilities, conduct disorder, and disruptive mood dysregulation disorder. The MDS stated the resident exhibited physical behavioral symptoms directed toward others such as hitting, kicking, pushing, and grabbing which occurred on 4-6 days during the 7 day review period and listed her cognition as severely impaired. A 3/28/23 Care Plan entry stated the resident was comforted by being on the floor and may position herself on the floor for comfort. An untitled documented, referred to by the Director of Nursing (DON) as a Walking Care Plan and updated 2/14/24, directed staff to provide 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 record review, policy review, and staff interview, the facility failed to carry out quality assurance (QA) activities in order to address problem-prone areas and create a plan for improvement. The facility reported a census of 23 residents. Findings: The Centers for Medicare and Medicaid Services (CMS) 2567, dated 6/29/23, listed the following concerns: F550, F609, F610. The CMS 2567, dated 11/30/23, listed the following concerns: F550, F609. The CMS 2567, dated 1/25/24, listed the following concerns: F689. Review of facility QA activities for the period of 1/1/24-5/19/24 revealed a 2/28/24 QA Committee sheet with the topic of all Plan of Correction (POC) tags. The QA documentation lacked further documentation related to the above concern areas including data collection, monitoring, audits, input from staff, and performance indicators. The facility lacked documentation the QA committee systematically identified, reported, tracked, investigated, analyzed and or utilized data to develop activities to prevent future adverse events. The current survey, conducted from…

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, record review, and staff interviews, the facility failed to maintain sufficient nursing staff to enable relief for scheduled nurses upon completion of their 12 hour shift, 4 times between 1/9/24 and 1/22/24, that required the nurse on duty to work in excess of 24 consecutive hours on 2 of the 4 dates, and the facility could not identify a plan for the future that would provide 100 percent certainty that the scheduled nurse on duty would have relief after their completed shift, if the scheduled relief staff failed to come to work. The facility reported a census of 27 residents. Findings include: The facility's nursing schedule revealed the following: 1/9/24 Staff F, Licensed Practical Nurse (LPN) scheduled to work from 6 a.m. to 6 p.m. Staff F, LPN, scheduled to work from 6 p.m. to 6 a.m. 1/12/24 Staff J, Registered Nurse (RN) scheduled to work from 6 a.m. to 6 p.m. Staff H, Agency LPN, scheduled to work from 6 p.m. to 6 a.m. 1/13/24 Staff H, LPN, scheduled to work from 6 a.m. to 11 a.m. Staff F, LPN, scheduled to work from 11 a.m. to 6 p.m. Staff G, RN,…

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

Based on record review, and staff interviews, the facility failed to provide the required 8 consecutive hours of Registered Nurse (RN) coverage on 4 dates between 1/10/24 and 1/25/24. The facility reported a census of 27 residents. Findings include: The facility's nursing schedule revealed the following: 1/12/24 Staff J, Registered Nurse (RN) scheduled to work from 6 a.m. to 6 p.m., but called off due to weather. Staff H, Agency LPN, scheduled to work from 6 p.m. to 6 a.m. 1/14/24 Staff F, LPN, scheduled to work from 6 a.m. to 6 p.m. Staff N, LPN, scheduled to work from 6 p.m. to 6 a.m. 1/18/24 Staff F, LPN, scheduled to work from 6 a.m. to 6 p.m. Staff F, LPN, scheduled to work from 6 p.m. to 2 a.m. Staff H, Agency LPN, scheduled to work from 2 a.m. to 8 a.m. 1/21/24 Staff F, LPN, scheduled to work from 6 a.m. to 6 p.m. Staff F, LPN, scheduled to work from 6 p.m. to 6 a.m. Payroll records between 1/10/24 and 1/25/24 revealed the following: Staff G, RN worked: 1/10/24 1/11/24 1/13/24 1/15/24 1/16/24 1/17/24 1/19/24 1/20/24 1/23/24 1/24/24 The Director of Nursing (DON) worked as 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 record review and staff interviews, the facility failed to follow directives as ordered and mandated in Level II PASRR assessments, and failed to submit a new PASRR assessment when a 90 day conditional Level II PASRR expired, for 2 of 2 resident's reviewed with Level II PASRR's (Resident's #1 and #4). The facility reported a census of 27 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment tool dated [DATE] revealed Resident #1 had diagnoses that included cerebral palsy, hemiplegia (paralysis on 1 side of the body), seizure disorder, conduct disorder, autistic disorder and severe intellectual disability, had severe cognitive impairment, rarely/never able to make herself understood or able to understand others, unable to speak, and had impaired vision not corrected by eye-glasses. The assessment documented the resident required maximal staff assistance to transfer from bed to chair, bathing, dressing, toileting and personal hygiene, unable to stand or ambulate, and had physical…

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, facility policy, and staff and resident responsible party interviews, the facility failed to develop a person-centered care plan that addressed specific safety needs of a resident, for 1 of 5 resident records reviewed (Resident #1). The facility reported a census of 27 residents. Findings include: The Quarterly Minimum Data Set (MDS) Assessment tool dated 10/26/23 revealed Resident #1 had diagnoses that included cerebral palsy, hemiplegia (paralysis on 1 side of the body), seizure disorder, conduct disorder, autistic disorder and severe intellectual disability, had severe cognitive impairment, rarely/never able to make herself understood or able to understand others, unable to speak, and had impaired vision not corrected by eye-glasses. The assessment revealed the resident required maximal staff assistance to transfer from bed to chair, bathing, dressing, toileting and personal hygiene, unable to stand or ambulate, and had physical behaviors directed at others, and other behaviors not directed at others, that occurred from 1 to 3 days of the 7 days 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, record review, and staff interviews, the facility failed to follow physician orders for wound care, and failed to ensure documentation was accurate and not falsified, for 1 of 5 resident records reviewed (Resident #3). The facility reported a census of 27 residents. Findings include: The Quarterly Minimum Data Set (MDS) Assessment tool dated 11/9/23 revealed Resident #3 had diagnoses that included diabetes, non-Alzheimer's dementia and back pain, had severe cognitive impairment. The MDS documented that the resident required extensive staff assistance for transfers to and from bed and chair, dressing, toileting, bathing and personal hygiene. Wound care orders directed by the physician included: 12/31/23 Paint left hallux (great toe) with Betadine (antiseptic solution) daily. 12/31/23 Cleanse left heel with Wound Cleanser, apply skin prep to peri wound, collagen pad to wound bed, cover with gauze and gauze wrap daily and as needed. 1/15/24 Paint right hallux and 2nd toe with Betadine twice daily. Review of the resident's January, 2024 Medication Administration…

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, and staff and resident responsible party interviews, the facility failed to provide adequate supervision to promote resident safety and prevent a resident to resident incident that resulted in an injury, for 2 of 5 resident records reviewed (Resident's #1 and #2). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 10/26/23 revealed Resident #1 had diagnoses that included cerebral palsy, hemiplegia (paralysis on 1 side of the body), seizure disorder, conduct disorder, autistic disorder and severe intellectual disability, had severe cognitive impairment, rarely/never able to make herself understood or able to understand others, unable to speak, and had impaired vision not corrected by eye-glasses. The assessment revealed the resident required maximal staff assistance to transfer from bed to chair, bathing, dressing, toileting and personal hygiene, unable to stand or ambulate, and had physical behaviors directed at others,…

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 record review the facility failed to have sufficient Registered Nurse (RN) coverage at least 8 consecutive hours a day for 8 of 37 days reviewed. The facility reported a census of 28 residents. Findings include: A staffing document titled December revealed there was no RN coverage December 3rd, 4th, 9th, 10th, 11th, 12th, 13th, or 19th. No additional coverage documentation was provided. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident#2 had scored a 15 out of 15 for the Brief Interview for Mental Status (BIMS), which indicated intact cognitive status. On 1/7/24 at 12:47 PM Resident #2 stated that most of the nursing staff who work with him are Licensed Practical Nurses (LPN), not RN. On 1/8/24 at 8:31 a.m. Staff A, Scheduler reported if both staff are listed as an LPN on the staffing document then they were unable to find RN coverage for that day either internally or from the agencies. The Director of Nursing (DON) at the time was 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 observation, interviews, and policy review the facility failed to maintain equipment and to prepare foods under sanitary conditions for 3 of 3 kitchen observations. The facility failed to repair the sanitizing triple sink, the Handwashing sink, and the cooking sink in a timely manner. The facility reported a census of 28 residents. Findings include: Observation on 1/7/24 at 11:11 AM were made in the kitchen as follows; a. The kitchen handwashing sink with a sign not to use it. b. In the clean side of the kitchen, a second sink was backed up on both sides with 3 inches of cloudy yellow liquid, an oily layer, and piles of a light ground up substance. c. The 3-section sanitizer sink was taped off and marked not to use. d. One sink remained in the clean prep area. e. The dishwashing area held a rented dish machine and one sink. f. The Dietary supervisor was in the food preparation area without a hair net. His baseball cap left 3 inches of hair uncovered. Observation on 1/9/24 at 11:13 AM in the kitchen as…

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 Council documentation, resident interviews, and staff interviews the facility failed to thoroughly act on grievances voiced in resident council for 2 of 2 months reviewed. The facility reported a census of 28 residents. Findings include: The Resident Council Meeting Summary dated 11/23/23 documented 14 of 25 residents attended. The follow up section noted the facility was working on smoking times and places from the last meeting. New meeting concerns included Certified Nurse's Aides (CNA's) bothered nurses too much on the weekends. A document titled Resident Meeting Nov. 29th concerns indicated residents reported issues of smoking hours and CNA's on the weekends bothering nursing. A document titled Resident Meeting Concerns 12/23 documented as follows; new nurses needed someone here to help them, residents needed rooms cleaned and trash picked up on the weekend, and more linens in their rooms. The Resident Council Meeting Summary dated 12/21/23 documented 15 of 27 residents attended. New…

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, record review, resident interview, and staff interview the facility failed to provide ready access to personal funds managed by the facility for 1 of 3 residents reviewed (Resident #3) and failed to provide quarterly statements for 11 of 11 residents reviewed. The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 15, indicative of intact cognition. The MDS indicated that it is very important for the resident to do his favorite activities, and go outside when the weather is good. The MDS documented the resident had diagnoses including Schizophrenia, Anxiety, and Bipolar Disorder. The Care Plan for Resident #3 last reviewed on 12/12/23 failed to reveal documentation regarding a Personal Funds Account with the facility. A section related to his mental health revised on 12/12/23 indicated smoking was an intervention to calm his anxiety. A document titled Trust Transaction History dated July 1, 2023 to January 9, 2024 included documentation for 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.

Based on observation, resident interviews, staff interviews, and policy review the facility failed to maintain a clean, safe environment with scheduled cleaning identified by visible carpet stains made by urine, blood, and feces which left noticeable odors in a resident room, the North hall, and a common television area near the dining room. The facility reported a census of 28 residents. Findings include: On 1/7/24 at 11:21 AM an observation of the common area and North hallway revealed 10 stains of various sizes on the carpet. The front half of the hallway and into the common area smelled strongly of urine. The hall remained accessible to residents and four residents sat in the common area with the television on. During a continuous observation on 1/8/24 from 11:25 AM to 11:42 AM, multiple North hallway residents walked and rolled through the affected areas. The nurse was located at the nursing cart which sat in the common area near the entrance to the North hall. The urine smell and the stains remained. On 1/9/24 at 12:18 PM an environmental tour of the building revealed 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 observation, interviews, and record review the facility failed to provide sufficient nursing staff to meet the acuity needs of the facility's resident population for 3 of 5 residents reviewed (Residents #1, #2, and #3). The facility reported a census of 28. 1. The Quarterly Minimum Data Set (MDS) for Resident #1 dated 10/26/23 documented diagnoses of cerebral palsy, quadriplegia, and disruptive mood dysregulation disorder. MDS Section C documented an inability to complete the Brief Interview for Mental Status (BIMS), indicative of severely impaired cognition. Section GG indicated the resident was always incontinent; dependent for toilet, tub, and chair transfers; and needed substantial/maximal assistance with toileting, bathing, and dressing. A Care Plan intervention initiated 12/20/23 indicated a poor awareness of personal care and health needs. A focus area revised 5/30/23 indicated the resident disrobed, tore her incontinence brief, and tried to eat it. A focus area revised 1/5/24 indicated 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, interviews, record review, and policy review the facility failed to complete an assessment for 1 of 4 (Resident #5) residents who smoked. The facility reported a census of 28. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #5 dated 10/19/23 documented diagnoses of Barrett's Esophagus without dysphasia (risk of esophageal cancer), heart failure, and chronic obstructive pulmonary disease. MDS Section C documented a Brief Interview for Mental Status (BIMS) of 13, indicative of intact cognition. Progress notes labeled Nurses Note, dated 12/16/23 and 12/20/23, documented the resident went out to smoke. A Care Plan with an admission date of 7/21/23 failed to include smoking goals or interventions. An observation on 1/7/24 at 1:28 PM included Resident #5 exiting the front door with another resident to smoke. They went to the designated area in resident parking and returned. On 1/9/24 at 4:26 PM observed the resident attempted to make it to the smoking area with his walker. The snow was too deep and he returned to the building. On 1/9/24 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 resident interview, staff interview, record review, facility investigation review, and facility policy review the facility failed to treat 1 of 3 residents reviewed with dignity. (Resident #3). The facility reported a census of 28. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses for Resident #3 included unspecified dementia, seizure disorder, anxiety, depression, respiratory and heart disease. The Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15, which indicated intact cognition. Functional ability section revealed Resident #3 independent with sit to stand, transferring and walking at least one-hundred fifty (150) feet. The Care Plan initiated 05/24/23 documented Resident #3 potential to be verbally aggressive, cursing, resistance to care, and name calling related to ineffective coping skills and poor impulse control. Interventions included to intervene before agitation escalates, guide away from source of distress, engage calmly 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 observation, staff interview, resident/family interview and record review the facility failed to ensure safe transport of resident in a wheelchair for 1 of 3 residents reviewed. (Resident #2). The facility reported a census of 28. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #2 dated 8/22/23 revealed resident scored 04 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. The MDS documented diagnoses including Cerebrovascular Accident (CVA) referring to recent stroke, contracture of right foot, contracture of muscle in right upper arm. The MDS documented unclear speech. Resident #2 coded for extensive physical assistance, referenced resident involved in the activity and staff provide weight bearing support for transfers, bed mobility, locomotion on and off the unit, dressing, toilet use and personal hygiene. The MDS revealed resident used wheelchair for mobility. The Care plan updated 8/22/23 documented Resident#2 had right side paralysis from CVA and aphasia (language disorder affects communication can occur…

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, record review and policy review, the facility failed to treat residents with divinity and respect for 5 of 5 residents reviewed (Residents #2, #5, #11, #18 & #24). The facility reported a census of 22 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #11 had diagnoses which included stroke, Parkinson's, diabetes mellitus, obesity. The MDS revealed that the resident required the assistance of 2 persons for bed mobility and toileting. Resident #11 had a Brief Interview of Mental Status (BIMS) of 15 which indicated an intact cognition. The Care Plan dated [DATE] directed staff to as follows; to adopt an accepting and consistent approach with Resident #11, do not avoid or overwhelm the resident, and maintain a safe environment for the. During an Interview on [DATE] at 9:47 AM Resident #11 stated Staff H, Certified Nursing Assistant (CNA) treated me like crap and she said what do you want! Resident #11 stated 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 resident and staff interviews, record review and policy review, the facility failed to report suspicion of verbal abuse and neglect affecting the psychosocial well being for 4 of 4 residents reviewed (Resident #5, #11, #18, #24). The facility reported a census of 22 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #11 had diagnoses including stroke, Parkinson's, diabetes mellitus, and obesity. The MDS revealed the resident required the assistance of 2 persons for bed mobility and toileting. Resident #11 had a Brief Interview of Mental Status (BIMS) of 15 which indicated an intact cognition. The Care Plan dated [DATE] directed staff to adopt an accepting and consistent approach with Resident #11, do not avoid or overwhelm the resident, and maintain a safe environment for the resident. During an Interview on [DATE] at 9:47 AM Resident #11 stated Staff H, Certified Nursing Assistant (CNA) treated me like crap and said, what do you want! Resident #11…

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 and staff interviews, record review and policy review, the facility failed to take action to investigate alleged violation of abuse to prevent further neglect and mistreatment of 4 of 4 residents reviewed (Resident #5, #11, #18, #24). The facility reported a census of 22 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed a diagnosis of a stroke, Parkinson's, diabetes mellitus, obesity and required the assistance of 2 persons for bed mobility and toileting. Resident #11 had a Brief Interview of Mental Status (BIMS) of 15 suggesting an intact cognition. The Care Plan dated [DATE] directed staff to adopt an accepting and consistent approach with Resident #11, do not avoid or overwhelm, and maintain a safe environment. During an Interview on [DATE] at 9:47 AM Resident #11 stated Staff H, Certified Nursing Assistant (CNA) treated me like crap and said, what do you want! Resident #11 stated she would turn on the call light to recieve care 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.

Based on observation, record review, policy review, and staff interview, the facility failed to store and prepare foods under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 22 residents. Findings include: 1. The initial kitchen observation on 06/26/23 at 9:52 AM revealed the following: A. Expired food items, located in the dry storage room: 1. mushrooms, expired 11/30/22 2. cinnamon streusel coffee cake mix, expired 12/29/22 3. enchilada sauce, expired 1/10/23 4. devil's food cake mix, expired 3/26/23 5. muffin mix, expired 6/8/23 6. lays chips, expired 6/6/23 7. tostitos chips, expired 6/20/23 B. The green detergent bucket was sitting in the sink with a rag in it. The sanitizing bucket was empty and dry. C. Food temperature testing logs for 6/24/23 dinner were not complete and the log for 6/25/23 was empty. 2. The second kitchen observation on 06/27/23 revealed the following: A. At 11:28 AM, observed Staff F, Dietary Aide, puree 2 sandwiches, coleslaw, and banana bread. The sandwich temperature was 55 degrees and placed on ice to cool. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure timely assessment and submission of veteran status (state law requirement) for 4 of 5 residents (Residents #6, #20, #24, and #176). The facility reported a census of 22 residents. Findings include: The facility admissions report for the survey year listed the following: Resident #6, admitted [DATE] Resident #20, admitted [DATE] Resident #24, admitted [DATE] Resident #176, admitted [DATE] The facility lacked documentation of VA Eligibility checks upon admission for the above residents. During an interview 06/28/23 at 3:08 PM, the Administrator confirmed some of the VA documentation was missing. During an email correspondence dated 6/29/23 at 9:16 AM, Staff D, Social Services, indicated there is no documentation for Resident #176. During email correspondence dated 6/29/23 at 11:19 AM, the Administrator stated they are unable to find the Veteran ' s policy.

Based on Quality Assurance(QA) signature sheets, policy review, and staff interview, the facility failed to ensure it held quarterly QA meetings throughout the survey year. The facility reported a census of 22 residents. Findings include: 1. Review of the CMS 2567 form dated 4/7/22 revealed, in part, deficiencies identified with notifications related to resident's discharging from skilled services, care plan revision, accidents, and kitchen sanitation. The current survey, completed 6/29/23 also identified concerns with the above areas. Review of the CMS 2567 form, dated 12/29/22, revealed, in part, deficiencies identified with staff dignity concerns. The current survey, completed 6/29/23 also identified concerns with the above area. A 3/13/23 facility Dietary: Kitchen sanitation documented a checklist related to proper kitchen sanitation. A 3/15/23 facility document Accidents documented a checklist related to the management of falls, elopements, and injuries such as skin tears, bruises, and burns. The facility lacked further documentation related to the identification and correction…

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 Quality Assurance(QA) signature sheets, policy review, and staff interview, the facility failed to ensure it held quarterly QA meetings throughout the survey year. The facility reported a census of 22 residents. Findings Include: The facility policy QAPI(Quality Assurance and Performance Improvement) Plan, dated 1/1/23, stated the committee would meet regularly to discus Performance Improvement Plans (PIPs) and progress. A QA Meeting Signature Sheet listed attendees of a QA meeting on 3/15/23. The facility lacked documentation of additional QA meetings held during the survey year from 4/7/22-6/26/23. In email correspondence, sent on 6/27/23 at 1:02 p.m., the Administrator documented he could not locate additional QA documentation. On 6/29/23 at 12:42 p.m., the Administrator stated the facility should conduct QA meetings quarterly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to document the reason for discharge from skilled services, the date of notification of Medicare Non-Coverage, and/or appeal decisions for 3 of 3 residents reviewed for completed Medicare services (Residents #176, #177, and #178). The facility reported a census of 22 residents. Findings include: 1. The Beneficiary Notice-Residents discharged Within the Last Six Months form documented Resident #176 discharged from Medicare Part A on 1/4/23. The facility lacked documentation that the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN) or the Notice of Medicare Non-Coverage (NOMNC) was completed. The MDS for End of PPS Part A Stay indicated that Resident #176 was discharged from Medicare A coverage on 1/4/23 with return not anticipated. The clinical record lacked documentation of discharge planning, ABN and NOMNC completion, and information regarding ability to appeal. 2. The Beneficiary Notice-Residents…

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, policy review, resident interview, and staff interview, the facility failed to carry out a root cause analysis and implement care plan interventions in order to prevent falls for 1 of 1 residents reviewed for falls(Resident #2). The facility reported a census of 22 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/18/23, listed diagnoses for Resident #2 which included anxiety, depression, and osteoarthritis(pain in the bones and joints). The MDS documented the resident required extensive assistance of 1 staff for transfers and walking and revealed the resident was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and transferring between the bed and chair or wheelchair. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. On 6/26/23 at 10:40 a.m., Resident #2…

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, policy review, resident interview, and staff interview, the facility failed to carry out a root cause analysis and implement interventions in order to prevent falls for 1 of 1 residents reviewed for falls(Resident #2). The facility reported a census of 22 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/18/23, listed diagnoses for Resident #2 which included anxiety, depression, and osteoarthritis(pain in the bones and joints). The MDS documented the resident required extensive assistance of 1 staff for transfers and walking and stated the resident was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and transferring between the bed and chair or wheelchair. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 6/26/23 at 10:40 a.m., Resident #2 stated that she fell…

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

Based on observation and staff interview, the facility failed to complete and post daily staffing that included name, date, census, number of staff, and hours worked for licensed and non-licensed staff. The facility reported a census of 22. Findings include: An observation on 06/26/23 at 12:06 PM revealed a posting area in the main lobby. The posting was dated 6/25/23. A binder on the same table, included previous documents showing posting gaps from 5/29/23 to 6/2/23, 6/4/23 to 6/7/23, 6/9/23, and 6/13/23 to 6/22/23. An observation on 06/27/23 at 08:00 AM showed a posting dated 6/26/23. An observation on 06/28/23 at 08:22 AM confirmed the daily posting remained 6/26/23. An interview on 06/26/23 at 12:06 PM with Staff G, Business Officer Manager/Human Resources, clarified that this is the only staff posting area. An interview on 06/26/23 at 12:15PM with the Administrator indicated that documents were completed at 6:00 AM daily with the charge nurse for posting.

Based on clinical record review, policy review, and staff interview, the facility failed to document attempts of non-pharmacological interventions prior to the administration of as needed (PRN) psychotropic medications for 1 of 1 residents reviewed for prn psychotropic medications(Resident #13). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 5/30/23, listed diagnoses for Resident #13 which included non-Alzheimer's dementia, depression, and chronic obstructive pulmonary disease. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Psychotropic Drug Use F 757 F758 effective 1/2023, directed staff to identify and note nonpharmacological approaches as an alternative to or an adjunct to prn psychotropic use. Care Plan entries, dated 5/29/23, directed staff to intervene before agitation escalated, guide away from the source of distress, engage calmly in conversation, and provide positive feedback for good behavior. The June…

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.