Casa De Paz Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician's orders for 4 of 10 residents reviewed (Res #7, #2, #9 and #10.) Resident #7 required close monitoring related to fluid overload and frequent Urinary Tract Infections (UTI) due to catheter use. Staff failed to notify the physician with extreme weight gain, and failed to change the catheter as ordered. Residents #7, #2, #9 and #10 had treatment orders that were not completed in the months of July and August with no corresponding explanation in the chart. The facility reported a census of 63 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability) She required total staff assistance with dressing, toileting, hygiene, and transfers. She had an indwelling urinary catheter and was always incontinent of bowel. He diagnoses included anemia, coronary artery disease, heart failure, hypertension, peripheral…

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 and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 66 residents. Finding Include: 1. Observation on 4/02/25 at 11:55 a.m., test tray was temped after the last resident on level 1 was served and temperatures were as follows: a. Ham- 103.3 degrees b. Mashed potatoes- 124.8 degrees c. Carrots- 107.1 degrees 2. Observation on 4/02/25 at 12:05 p.m., level 2 room trays were sitting on the kitchen carts ready to pass. Staff A, Certified Nursing Assistant (CNA) began passing meal trays. Staff A verified she was taking meal tray into Resident #59's room. Stopped CNA and had staff check the temperature of the food. The temperatures were as follows: a. Ham- 97 degrees b. Mashed potatoes- 131 degrees c. Carrots- 96 degrees. Kitchen staff removed the tray and returned to the kitchen with the tray to reheat the food to the proper temperature. Interview on 4/02/25 at 12:27 p.m., with 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, resident grievances, resident interview, staff interview, and policy review the facility failed to ensure 3 of 3 residents ' personal property was protected from loss or theft (Resident #12, #39, #51) . The facility reported a census of 66 residents. Findings include: 1. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed an admission date of 10/15/24 to the facility from a short term hospital stay. Interview on 3/31/25 at 11:02 AM with Resident #12 revealed she had missing clothing. Resident #12 further revealed she was missing shorts, and pants. Resident #12 stated she had told staff, but did not file a grievance. Review of facility provided inventory list with Resident #12's name and date of 2/27/25 revealed no shorts on the list and 10 pairs of pants. 2. Review of Resident #39's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition.…

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 and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 6 residents (Resident #60) reviewed for PASRR requirements. The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 documented diagnoses psychotic disorder, aphasia and diabetes mellitus. The MDS included a Brief Interview for Mental Status (BIMS) score that was not completed. The MDS revealed diagnosis of psychotic disorder. Review of the active diagnosis list in the clinical record revealed the following diagnosis of delusional disorder. The Care Plan with revision date of 3/7/25 revealed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch and failed to include enhanced barrier precautions for 3 out of 20 sampled residents reviewed for comprehensive care plans (Resident #39, #48 and #66). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnoses of depression, non-Alzheimer's Dementia and acute respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Fluoxetine (antidepressant medication) daily with a start date of 10/6/24 b. Olanzapine (antipsychotic medication) daily with a start date of 3/20/24 c. Morphine (narcotic medication) as needed with a start date of 3/18/25 Review of the Care Plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, resident interview and staff interviews, the facility failed to prevent accidents and hazards by not properly using a motion detector to prevent a fall that caused the need for an emergency room (ER) visit, facial bruising, laceration to the forehead and the need for pain medication for 1 of 3 residents reviewed (Resident #3). The facility also failed to use adequate transfer techniques while using a mechanical lift for 2 of 3 residents observed (Resident #8 and #44). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of heart failure, respiratory failure and osteoarthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 02, which indicated severe cognitive impairment The MDS also showed Resident #3 dependent for toileting hygiene and baths.The resident also required substantial assistance for transfers. Observation on 3/31/25 at 12:20 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 and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #48 and #66). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnoses of depression, non-Alzheimer ' s Dementia and acute respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Fluoxetine (antidepressant medication) daily with a start date of 10/6/24 b. Olanzapine (antipsychotic medication) daily with a start date of 3/20/24 Review of the Care Plan with a revision date of 3/14/25 lacked non pharmacological interventions and targeted behaviors for the antidepressant and antipsychotic medications. 2. The MDS assessment…

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, resident interview, staff interview, and policy review the facility failed to provide appropriate infection prevention practices related to contact and droplet precautions for 1 of 3 residents (Resident #39) reviewed. The facility reported a census of 66 residents. Findings include: Review of Resident #39's Minimum Data Set (MDS) dated [DATE] revealed an admission date to the facility of 11/29/24. The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of Resident #39's Electronic Healthcare Record (EHR) page titled Physicians Orders revealed an order for Capecitabine oral tablet 500mg give 4 tablets by mouth 2 times a day for chemotherapy related to malignant neoplasm of the rectum. Observation on 3/31/25 at 11:30 AM revealed a sign by Resident #39's door stating that Resident #39 was on contact and droplet precautions. Observation on 3/31/25 at 12:47 PM Staff C Certified Medication Aide (CMA) went into Resident #39's room without…

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 video footage review, staff interviews, and facility policy review the facility failed to count 4 of 4 resident's (Resident #1, #2, #3, and #17) narcotics after they were signed for upon delivery from the pharmacy. The facility reported a census of 67 residents. Findings include: Review of the facility's video footage dated 12/26/24 revealed the following: -At 5:59 PM a male pharmacy staff member entered the building and Staff A Registered Nurse (RN) greeted him at the receptionist's desk, located across from the front entrance. Staff A removed pink and white slips out of the red and white bags. Staff A is seen signing the sheets and handing them to the pharmacy staff member, placing the bags to the side. -At 6:02 PM Staff A picked up a black box and left the receptionist's desk. Staff A failed to go through the medication bags to count the medications. A pink document titled Packing Slip, dated 12/26/24 document the following medications were delivered to the facility on [DATE]: -morphine sulfate…

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 the observation, video footage review, staff interviews and facility policy review the facility failed to appropriately store the medications of 19 residents after they were signed for upon delivery from the pharmacy. The facility reported a census of 67 residents. Findings include: Review of the facility's video footage dated 12/26/24 revealed the following: -At 5:59 PM a male pharmacy staff member entered the building and Staff A greeted him at the receptionist's desk, located across from the front entrance. Staff A removed pink and white slips out of the red and white bags. Staff A is seen signing the sheets and handing them to the pharmacy staff member, placing the bags to the side. -At 6:02 PM Staff A picks up a black box and leaves the receptionist's desk. -At 6:04 PM three family members stood at the receptionist's desk, where the medication bags were left opened and unsupervised by staff. A fourth family member came to the desk and wrote in the sign in/out binder, within arm's reach of 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 observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 67 residents. Finding Include: 1. Interview on 7/14/24 at 8:59 a.m., with Resident #5 revealed the food is quite often cold. Resident #5 further revealed she does not ask staff to warm it up as she knows the staff work hard and doesn't want to bother them but she really doesn't want to eat the food cold but has to because it is the meal. 2. Lunch tray requested on 7/14/24 for lunch. Staff served chicken, mashed potatoes and gravy, mixed vegetables and banana cream pie. Temperature of food was checked as follows: Chicken- 126.1 degrees Mashed potatoes and gravy- 121.1 degrees Mixed vegetables- 106.4 degrees Banana Cream Pie- 33.1 degrees 3. Interview on 7/14/24 during lunch service on the first floor revealed Resident #5 said her food was cold and the only item that was hot was her coffee. 4. Observation on 7/14/24 of lunch trays on 2nd floor being passed in the dining room. Verified with 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 observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 67 residents. Findings include: An initial kitchen tour conducted on 7/12/24 at 10:41 a.m., revealed the following observations: The kitchen fridge revealed the following items ready for service: a. Open gallon of white milk open with no open date b. Chef salads prepared undated c. Deli sandwiches prepared on a plate undated d. Tuna salad sandwiches on a plate undated e. Tube of whip topping open laying on shelf uncovered and undated f. Thickened water, open, undated g. Thickened juice, open, undated h. Thickened dairy drink, open, undated The kitchen freezer revealed the following items ready for service: a.Ice cream scooped into styrofoam bowls stacked on top of eachother uncovered and undated The dry storage area revealed the following: a. Spilled flour on the floor b. Dead bugs appearing along the edges of the room c. Two containers of pudding packages laying on the floor under the shelving…

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 infection control policy the facility failed to pass clean linens to residents rooms.The facility reported a total census of 67 residents. Findings include: Observation on 7/13/24 at 9:13 a.m., Staff A, laundry aide pushed a laundry cart with open sides with clean clothing protectors in it. Towel laid across the top of the clean linen leaving the sides of the laundry cart open and open to contamination. Observation on 7/13/24 at 12:14 p.m., Staff A took the laundry cart upstairs with personal clothing and clothing protectors covered by a towel, arms of the personal laundry and sides of personal clothing laying over the side of the cart exposed and open to contamination. Review of the facility provided policy revealed Laundry handling of Linen dated 3/2015 revealed under transportation of linen revealed cover clean linen to protect from contamination during transport. Interview on 7/14/24 at 2:23 p.m., with the Administrator revealed she was not aware the laundry cart needed to be covered but she will make sure the laundry has what they need…

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

Based on personnel file reviews, staff interviews, and policy reviews the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 3 of 7 employees reviewed (Staff B, C, D). The facility census was 55. Findings include: On 4/10/24 Staff B, Cook's personnel file contained the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information dated 1/24/24. Staff B was hired on 1/14/24. On 4/10/24 Staff C, Dietary Aide ' s personnel file contained the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information dated 1/25/24. Staff C was re-hired on 1/14/24. On 4/10/24 Staff D, Cook's personnel file contained the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information dated 1/25/24. Staff C was re-hired on 1/14/24. On 4/10/24 at 11:11 AM the Administrator stated that Staff B, C, D all began working directly for…

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 interview the facility failed to ensure residents received restorative exercises as planned for 4 of 4 resident's reviewed (Resident #3, #16, #20 and #37). The facility reported a census of 55 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #3 scored 11 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The resident was dependent with toileting hygiene, bathing, dressing, and personal hygiene. The resident demonstrated a functional limitation in range of motion (ROM) of both lower extremities. The resident had diagnoses including age related osteoporosis, and osteoarthritis. The Care Plan revised 11/20/21 identified the resident required assistance with all activities of daily living (ADL's) related to a lack of motivation, impaired cognition, impaired communication, pain, incontinence, limited ROM to lower extremities, and required assist with transfers. The interventions…

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 serve residents the therapeutic menus as ordered for 5 of 5 reviewed. Residents #25, #5 and #43 had pureed diet orders and staff served them oatmeal that was not pureed. Residents #36 and #12 had mechanical soft diets, staff served them corn with the mixed vegetables. The facility reported a census of 55 residents. Findings include. 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #25 did not have a Brief Interview for Mental Status (BIMS) score because he was rarely/never understood. The resident was totally dependent on staff for sit to standing and toileting transfer and he was on a mechanically altered diet. The Care Plan last revised on 7/17/23, showed that he had the potential for altered nutrition, he was able to eat independently, staff were directed to serve the diet per doctors order. The resident had limited range of motion to right arm due to contracture related to stroke, but he was able to eat independently.…

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

Based on observations, staff interviews and policy review, the facility failed to ensure food was labeled with dates after opening, staff complete hand hygiene before applying gloves and when removing, supplies and ingredients are stored in a safe and sanitary way, and ensure hair is completely covered with a hair net. The facility identified a census of 55 residents. Findings include: 1. An initial Kitchen tour conduct on 4/8/24 at 10:46 AM, of the kitchen revealed the following: a. Walk in refrigerator had multiple cups of fruit, a chunk of cheese, and more fruit on an upper shelf not dated. b. The inside door of the walk in refrigerator had white spatter on the inside. c. In the dry storage room on the bottom shelf, the large sugar canister had a cup stored in it and the large flour canister had a mug in it. 2. A follow up Kitchen tour conducted on 4/9/24 at 9:50 AM, of the kitchen revealed the following: a. In the dry storage room, the large flour canister had a mug in it. b. In the dry storage room a case of straws was sitting on the floor. c. Walk in refrigerator had a bag of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to notify the ombudsman office of a facility initiated discharges for 3 of 3 residents (Residents #30, #25, #3) reviewed. The facility reported a census of 55 residents. Findings include: 1. Resident #30's Minimum Data Set (MDS) dated [DATE] assessment identified Brief Interview for Mental Status (BIMs) score of 15, indicated intact cognition. The MDS included diagnoses of anemia, coronary artery disease, heart failure (heart doesn't pump blood as it should), end stage renal disease (kidney), diabetes mellitus and respiratory failure. Review of the Clinical Census revealed Resident #30 was on an unpaid hospital leave in January 2024 during the following dates: 1/4/24 to 1/11/24 1/22/24 to 1/29/24 Review of the facility Admission/Discharge report dated 2/1/24 used to track discharges and notify the Ombudsman office revealed Resident #30 was not listed on the report. On 4/10/24 at 12:15 PM, the Administrator acknowledged and verified…

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 Electronic Health Record review (EHR) and staff interviews the facility failed to submit a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual assessment within the required timeframe for 1 out of 17 residents reviewed (Resident #49). The facility census was 55. Findings include: The review of Resident #49 ' s MDS assessment dated [DATE] lacked a transmission date. On 4/10/24 at 9:21 AM Staff F, MDS Coordinator, acknowledged the 2/6/24 MDS Assessment had not been submitted. Staff F stated a correction would be made with the submission of the 2/6/24 MDS assessment. On 4/10/24 at 10:52 AM the Administrator stated expected the MDS assessments would be completed and submitted within the required timeframes. The Administrator was not aware of other instances where the MDS assessments were not completed according to the required timeframes. On 4/10/24 at 12:45 PM the submission report for the 2/6/24…

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 interview, record and policy review, the facility failed to ensure that residents received medications as orders for 1 of 3 residents. After a medication change, staff continued to administer the previous order to Resident #38. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #38 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability.) The resident had frequent pain, and received scheduled, and as needed pain medication. The resident's diagnosis included; diabetes mellitus, Parkinson's Disease, malnutrition and anxiety disorder. The Care Plan updated on 11/12/23, showed that Resident #38 had a communication problem related to Parkinson's Disease, and a mental health diagnosis. He had pain related to Parkinson's, staff were directed to assess pain every shift, and evaluate the effectiveness of pain interventions. The resident was able to call for assistance when he was in pain, On 4/10/24 at 6:25…

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 observation, record review and staff interview, the facility failed to provide appropriate care to prevent urinary tract infection for 1 resident reviewed (Resident #37). The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #37 scored 11 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The resident was dependent with toileting hygiene and had an indwelling suprapubic urinary catheter. The resident had diagnoses including non-Alzheimer's dementia and a (left femur) fracture. The Care Plan revised 3/26/24 identified the resident had an indwelling suprapubic catheter. The goal with a target date of 6/24/24 included minimizing the potential of complications through the next review with the intervention to check the tubing for kinks each shift. The Progress Notes dated 11/14/23 at 10:52 p.m. documented the resident was post antibiotic treatment for urinary tract infection (UTI).…

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 ensure that residents were free from unnecessary psychotropic medications for 1 of 5 residents reviewed. Resident #43 had an order for Haloperidol as needed (PRN), and a review of the clinical record revealed that the order continued past the 14-day limit for PRN psychotropic medication use. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #43 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficits). The resident did not have physical behavioral symptoms such as hitting, kicking or grabbing, did not scream at others and did not reject cares. The resident was totally dependent on staff assistance for transfers and with eating. Diagnosis for Resident #43 included non-Alzheimer's Dementia, anxiety disorder and respiratory failure. The Care Plan for Resident #42, last revised on 2/19/24, showed that she used psychotropic medications.…

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 interview the facility failed to ensure residents remained free from significant medication errors for 1 of 17 residents reviewed (Resident #40). The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #40 scored 9 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The resident was independent ambulating with a walker. The resident had diagnoses including non-Alzheimer's dementia. The resident took antidepressant and antipsychotic medications. The Care Plan revised 2/7/23 identified the resident used psychotropic medications. The goal to minimize the potential of complications while on psychotropic medication. The interventions included monitoring/recording/reporting to the NP as needed side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and policy review the facility failed to prepare and serve pureed food to meet the nutritional needs of 3 of 3 residents reviewed (Residents #5, #25, #43). The facility reported a census of 55 residents. Findings include: A facility form titled Diet Type Report dated 4/8/24 identified three residents (Resident #5, #25 and #43) who received a pureed texture diet. On 4/9/24 at 11:00 AM observed Staff A, [NAME] took four Rueben sandwiches and placed the sandwiches in the Robo Coupe. She then added chicken broth to the contents. After she was finished pureeing the sandwiches, she poured the contents into a sprayed pan, covered the pan with aluminum foil and placed the pan in the oven. Staff A did not measure the total volume of the food after it was pureed to determine the appropriate portion or scoop sizes. On 4/9/24 during noon meal service, observed Staff A, [NAME] serve one scoop full of the #6 scoop of pureed [NAME] sandwich to Resident #5, #25 and #43. On 4/9/24 at 12:40…

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

Based on interview and record review, the facility failed to ensure the binding arbitration agreement provided for the selection of a venue that was convenient to both parties for 3 of 3 residents reviewed for binding arbitration (Residents #107, #52, #44). The facility reported a census of 55 residents. Findings include: Review of the undated facility Voluntary Arbitration Agreement, provided by the Administrator on 4/8/24, revealed no evidence for the selection of a venue that was convenient to both parties. Review of the undated facility Voluntary Arbitration Agreement Program Guide, provided by the Administrator on 4/8/24 and attached to the arbitration agreement, documented the dispute would be decided at an arbitration hearing at a court reporter's or attorney's office, which would occur within 6 months /180 days of the request for arbitration. Review of Resident #107, #52 and #44 ' s electronically signed Voluntary Arbitration Agreements failed to include the selection of a venue that was convenient to both parties. Review of Resident #107, #52 and 44 ' s electronically…

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, facility documents, pest management company documents, pest management staff interview, resident and staff interviews, the facility failed to maintain pest control in the facility. Findings include: Interviews, and concurrent observations of mouse traps in resident rooms, with the following residents reporting: 1. In an interview on 1/16/24 at 2:55 PM, Resident #1 reported that she saw a mouse in her room as well as in her bed. She reported this to the Maintenance Director and told her that the pest control company was coming tomorrow but she never saw pest control staff at the facility. 2. In an interview on 1/17/24 at 3:00 PM, Resident #5 reported that he saw a mouse in his room. He reported this to both the Maintenance Director and the Administrator over 2 months ago. 3. In an interview on 1/17/24 at 11:55 AM, Resident #11 reported she had mice in her room. She reported it to one of the Certified Nurse Assistants (CNA) who said that she passed the information on to the Maintenance…

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.