Westwood Specialty Care

Based on observations and staff interview, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 2 of 3 residents observed (Resident #1 and #4). The facility reported a census of 77 residents. Findings include: 1. Observation on 12/23/25 at 12:14 p.m., of Staff C, Certified Nursing Assistant (CNA) empty Resident #1's catheter bag. Staff C cleaned the catheter end prior to emptying the urine from the bag. Staff C emptied the urine into the graduate, after the bag was empty she closed the end and without cleaning the end placed back into the bag and cleaned up her supplies for the resident. When completed, she removed gown and gloves and performed hand hygiene. 2. Observation on 12/29/25 at 1:41 p.m., of Staff D, CNA assisting Resident #4 to the bathroom. When resident #4 was completed in the bathroom, Staff D assisted her to a standing position and then took a disposable wipe and wiped from front to back with the first wipe, used the same side and wiped the rectum 3 times and disposed of it into the trash. Took…

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 provide and maintain accurate resident records to reflect an incident occurring in the facility for 1 of 3 residents (Residents #4). The facility reported a census of 77 residents.Findings include: The MDS assessment dated [DATE] for Resident #4 documented diagnoses of muscle wasting, dependence on a wheelchair and nerve damage. The MDS showed moderate cognitive impairment for daily decision making. The Clinical Physician Orders for Resident #4 dated 7/18/23 showed tramadol 50 milligram (MG) three times a day ordered for pain. The Controlled Drug Count Record dated 9/16/25 for Resident #4 showed Staff F, Certified Medication Assistant (CMA) failed to sign the count record at 6 AM. The Individual Narcotic Record for Resident #4 showed that on 9/16/25 PM shift the tramadol tablet count to be 30 tablets. The 9/17/25 AM tramadol showed the count to be 28 tablets. The September Medication Reconciliation for 2025 showed Staff F, CMA administered…

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 assure residents were free from significant medication errors for 1 of 3 resident reviewed (Resident #1). The facility reported a census of 77 residents.Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a diagnosis of heart failure, renal insufficiency and stroke. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The Medical Diagnosis report for Resident #2 showed no diagnosis of Diabetes [NAME]. The Clinical Physician Orders for Resident #2 showed no orders of jardiance or gabapentin. The Progress Note dated 11/3/25 at 7:30 AM for Resident #1 documented the following:Resident received wrong AM medications this AM. Spit out most of all medications. Received jardiance and gabapentin, but medications not ordered. Resident verbalizes understanding of receiving wrong medications. Denying pain and no signs of pain observed.Vitals within normal…

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 provide and maintain accurate resident records to reflect an incident occurring in the facility for 2 of 2 residents (Residents #2 and #4). The facility reported a census of 77 residents.Findings include: 1. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of muscle wasting, repeated falls and disorientation. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Review of the untitled facility investigation dated 10/8/25 at 6:02 p.m. revealed an incident investigated by the Administrator involving the disappearance of $105 in cash from the pouch attached to Resident #2's walker. In an Interview on 12/30/25 at 2:01 PM, the Administrator stated that Resident #2 returned from the hospital and requested to speak with him. The Administrator went to the resident's room, where the resident reported that $105 was missing, consisting of one $100 bill and five $1 bills. 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 observation, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 1 of 3 residents observed (Resident #6). The facility reported a census of 80 residents.Finding include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of stroke, dementia and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.Observation on 10/29/25 at 11:04 AM revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA completed hand hygiene and donned gloves. Staff B removed the soiled brief, removed gloves, performed hand hygiene and donned gloves. Staff B then used cleansing wipes to wipe down the right and left side of the groin. Staff B obtained a new cleansing wipe, cleansed the entire groin, perineum area, shaft and around the urethral area of the penis. Staff B then…

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

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 81 residents. Findings include: The PBJ Staffing Data Report run date 3/13/25 for Quarter 1 2025 triggered for excessively low weekend staffing and one star staffing rating. Review of weekend staffing schedules for Quarter 1 months of October, November, and December revealed equal floor staffing during the week and the weekend. Decreased management staffing reported on the weekend. On 3/26/25 at 2:05 PM the Administrator stated Monday through Friday more management were present at the facility and the MDS Coordinator's hours went into floor staffing. The Administrator revealed the facility had 2 ADON's as well as a DON that works during the week. The Administrator said the DON was coming in to help with a few call in's on the weekend. The Administrator stated 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 and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch, PASARR recommendations, oxygen usage and fluid restrictions for 4 out of 20 sampled residents reviewed for comprehensive care plans (Resident #20, #45, #72 and #231). The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder, depression and vascular dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Sertraline (antidepressant medication) 1 tablet daily for depression with a start date of 11/17/24. b. Morphine Sulfate (opioid medication) three times daily for pain with a start date of 3/13/25. c. Haloperidol (antipsychotic medication) as needed for agitation…

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, document review, resident interview, staff interview, and policy review the facility failed to follow the menu and prepare food to meet the nutritional needs for 19 of 81 residents reviewed. The facility reported a census of 81 residents. Findings include: 1. Observation on 3/25/25 at 12:07 PM to 12:27 PM during continuous observation no wheat rolls were delivered with the first 18 plates served in the dining room. Review of a document titled Menu for the Week of 3/23/25 through 3/29/25 revealed that lunch on 3/25/25 consisted of BBQ pork, American fried potatoes, baked beans, wheat roll, and fresh orange slices. Interview on 3/25/25 at 1:01 PM with the Certified Dietary Manager (CDM) revealed her expectations would be for menus to be followed. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #66 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 3/17/25 at 11:37 AM Resident #66 stated she is shy and ate in her room and she was the last…

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, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 4 of 5 residents reviewed ( Residents #4, #28, #36, and #50). The facility reported a census of 81 residents. Findings include: 1. Review of Resident #28's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on 3/16/25 at 3:09 PM with Resident #28 revealed the food is often cold when it should be hot. 2. Review of Resident #36's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 3/16/25 at 2:10 PM with Resident #36 revealed the food is cold. Resident #36 revealed the biscuits were cold that morning. 3. Review of Resident #50's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 3/17/25 at 10:50 AM with Resident #50 revealed the food has been cold several times instead of hot since 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, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 81 residents. Findings include: During the initial kitchen walk through on 3/16/24 at 11:45 AM it was observed that there were four drawers when first entering the kitchen by the coffee machine. Inside the drawers was noted to have multiple dark colored stains and miscellaneous debris along with lids for cups, and straws. During continuous observation on 3/25/25 from 12:07 PM until 12:24 PM it was observed that Staff P cook donned a glove on the left hand and then opened a bag with buns inside. Staff P then reached into the bag and removed a bun with the same gloved hand and placed the bun onto a plate for service. The glove was then doffed and hand hygiene was completed. During an interview on 3/25/25 at 1:01 PM with the Certified Dietary Manager (CDM) revealed her expectations would be for the kitchen area and drawers to be clean, and for staff to change gloves at the appropriate times.…

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, interview, and facility policy the facility failed to have the minimum number of required members for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 87. Findings include: Review of the facility documentation titled Quality Assurance Committee Meeting Sign-In sheet date 11/12/24 lacked signatures of one other staff member present. Review of facility provided policy titled Quality Assurance and Performance Improvement (QAPI) Program- Governance and Leadership revised March 2020 the following individuals serve on the committee include the Administrator, Director of Nursing, Medical Director, Infection Preventionist and representative of other departments as requested by the Administrator. Interview on 3/27/25 at 2:44 p.m., with the Administrator revealed the appropriate number of staff should have been at the meeting as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Electronic Health Record (EHR) review, policy review, resident interview and staff interview the facility failed to provide appropriate infection prevention practices by not donning appropriate Personal Protective Equipment (PPE) and failed to provide appropriate infection prevention practices during administration of medications for 3 of 8 residents reviewed (Resident #51, #57, and #72). The facility reported a census of 81 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #51 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS indicated Resident #51 received dialysis treatments. On 3/16/25 at 1:42 PM Resident #51 stated staff never wear gowns in her room when they provide personal care for her. Review of Resident #51's Medication Administration Records - Treatment Administration Records documented a Physician's Order for enhanced barrier precautions due to dialysis port every shift ordered 9/12/2024. 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 policy review, document review, and staff interview the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. The facility reported a census of 81 residents. Findings include: On [DATE] at 10:34 AM Staff A, Regional Nursing Consultant stated after Staff B, Registered Nurse (RN) was suspended. Staff A explained it was identified that Staff B's training for dependent adult abuse / mandatory reporter expired and the facility did not want him to complete the course during suspension. On [DATE] at 1:47 PM the Administrator stated the facility's expectation was that the training for mandatory reporters would have been completed prior to the expiration date unless the staff was suspended. The Administrator acknowledged that Staff B's mandatory reporter training was…

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 Records (EHR) review, staff interviews, resident interview and policy review the facility failed to provide an opportunity for bath or shower to 1 of 4 residents reviewed (Resident #21). The facility reported a census of 81 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #21 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 3/17/25 at 10:14 AM Resident #21 stated that his doctor recommended baths Sunday, Monday, Wednesday and Friday. Resident #21 revealed he would like a bath 4 times a week. Resident #21 said he had told staff at the facility that he wanted a bath 4 times a week. Resident #21 stated the Administrator asked him why he needed it 4 times a week. Resident #21's MDS dated [DATE] indicated independence with bathing. Review of Resident #21 Medication Administration Record - Treatment Administration Record (MAR-TAR) documented a Physician's Order for showers only, not tubs or hot tubs. Give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent falls for 1 of 3 residents reviewed (Resident #231). The facility reported a total census of 87 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #231 documented diagnoses of unsteadiness on feet, need for assistance with personal care and repeated falls. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicates no cognitive impairment. Review of facility provided document titled Incidents by Incident Type dated 3/26/25 revealed Resident #231 had witnessed fall incidents on 12/7/24, 12/13/24 and 12/16/24. Review of the Care Plan with a cancelled date of 3/10/25 revealed the following information: a. Lacked interventions to prevent further falls on 12/7/24 and 12/13/24. b. Ambulation/Mobility 2 assist with gait belt and 1 assist with mobility in my room using bilateral platform walker with 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.

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 related to high risk medications in 1 out of 5 sampled residents reviewed (Resident #20). The facility reported a census of 87 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder, depression and vascular dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Sertraline (antidepressant medication) 1 tablet daily for depression with a start date of 11/17/24. b. Morphine Sulfate (opioid medication) three times daily for pain with a start date of 3/13/25. c. Haloperidol (antipsychotic medication) as needed for agitation with a start date of 3/19/25. d. Lorazepam (anti-anxiety medication) twice daily for anxiety with a start date of 3/6/25. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, resident family interviews, staff interview, electronic health records (EHR), document review and policy review the facility failed to maintain medical records on each resident that were complete and accurate by failing to document a fall in the electronic health records and not keeping an accurate up to date resident inventory list for 2 of 8 residents reviewed (Resident #21 and #231). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #21 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 3/17/25 at 10:16 AM Resident #21 stated he told a nurse he was missing a hearing aid and the nurse asked if he looked under his bed but the hearing aid was never found. Resident #21 stated he took the hearing aid out and went to bed. Resident #21 stated he took both out with one hand and laid them on the table then in the morning one was there and the other was not. Resident #21…

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, record review, hospital staff, staff and family interview the facility failed to follow physician's orders for 1 of 3 (Resident #1) residents reviewed. The facility also failed to appropriately enter a physician's order in to the Electronic Health Record (EHR) for 1 of 3 (Resident #2) residents reviewed. The facility reported a census of 76 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/19/24, Resident #1's cognitive skills for daily decision-making skills was not assessed. Resident #1 utilized a wheelchair and was frequently incontinent of urine and bowel. The MDS listed the following diagnoses: dementia, urinary tract infection (UTI), depression, autoimmune hepatitis, lymphedema, and pulmonary hypertension. The Care Plan focus area with an initiation date of 11/14/22 documented Resident #1 has a UTI related to incontinence of urine and stool. The care plan instructed staff to administer her antibiotics as ordered. The Care Plan focus area with an initiation date of 12/18/23…

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 observations, record review, resident, staff and hospital staff interview and policy review the facility failed to ensure 1 of 3 residents (Resident #2) reviewed were assisted with cleaning their dentures and that her peri-area was adequately cleansed appropriately prevent moist associated skin damage (MASD). The facility reported a census of 76 residents. Findings include: According to a quarterly MDS assessment tool with a reference date of 5/1/24, documented Resident #2 had a BIMS score of 13, suggesting no cognitive impairment. The MDS listed the following diagnoses for Resident #2: stroke, anemia, peripheral vascular disease, renal failure, dementia, hemiplegia/hemiparesis, and depression. The Care Plan focus area with an initiation date of 11/16/23 documented she required the assistance of one staff for toileting and personal hygiene. The Care Plan focus area with an initiation date of 12/4/23 instructed staff to assist Resident #2 with oral care to reduce irritation from food. Review of the Fire Rescue Patient Care Report dated 7/17/24 documented when the Emergency…

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 all residents had their call light within reach in their rooms for 1 of 1 resident reviewed, (Resident #31). The facility reported a census of 68 residents. Findings include: 1. Observation on 6/3/24 at 11:51 a.m., Resident #31 ' s call light over the end of the bed Resident #31 is unable to reach the call light. 2. Observation on 6/5/24 at 10:08 a.m., Resident #31 ' s call light laying across the end of the bed. Resident #31 is unable to reach the call light. 3. Observation on 6/6/24 at 9:46 a.m., Resident #31 ' s call light laying at the end of the bed. Resident #31 is unable to access the call light. Review of the facility provided policy titled Answering the Call Light with a revision date of March 2021 revealed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Interview on 6/6/24 at 10:11 a.m., with Regional Nurse Consultant revealed she would expect the staff to have the call light within reach for Resident #31 even though 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 clinical record review, resident interview and facility policy, the facility failed to ensure bed hold notice was sent to resident and or the resident's responsible person after giving a verbal consent when residents transferred out of the facility for 1 of 3 residents reviewed, (Residents #18). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 documented diagnoses of heart failure, diabetes mellitus and asthma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Interview on 6/3/24 at 2:32 p.m., with Resident #18 revealed he went to the hospital and got a bill that he was unaware of. Resident #18 revealed the facility called his sister and she gave a verbal to hold the bed but was unaware of what the cost was for each day the bed was held. Resident #18 further revealed he nor his sister ever seen a bed hold form from his hospitalization. Review of Resident #18 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to resubmit Preadmission Screening and Resident Review (PASRR) after a 180 day short stay approval expired on [DATE] for 1 of 1 residents reviewed for PASRR requirements, (Resident #45). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 documented diagnoses of depression, anxiety disorder, post traumatic stress disorder (PTSD), bipolar disorder and homelessness. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the clinical record revealed a Notice of PASRR Level II Outcome dated [DATE] revealed the PASRR determination was a short term approval with specialized services- limited time with an expiration date of [DATE]. Review of the clinical record revealed a Notice of PASRR Level I Outcome dated [DATE] was the next PASRR competed with determination PASRR Level I Determination of Level I…

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 interview, and staff interviews the facility failed to provide professional standards of care by not following physician orders and by not entering orders into the electronic health record for 1 of 21 residents reviewed, (Resident #36). The facility reported a census of 68 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 documented the Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The MDS diagnosis included unsteadiness on feet, need for assistance with personal care and muscle atrophy. Observation on 6/3/24 at 3:17 PM showed Resident #36 wearing a right foot cam boot while ambulating the hall. In an interview on 6/3/24 at 3:33 PM, Resident #36 explained that she fractured her ankle as a result of fall. Resident #36 reported that she wore another ankle brace inside the boot. When asked how long she had to wear the boot and brace, Resident #36 stated that she didn' t know. When asked…

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, policy review, and staff interview, the facility failed to notify the primary care provider (PCP) for worsening of a deep tissue injury (Resident #16) as well a delay in initiating wound care treatment on a newly identified deep tissue injury (#4) for 2 of 4 resident identified with a pressure injury. The facility reported a census of 68. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) of 12 indicating a moderate cognitive impairment. The MDS further indicated Resident #16 is at risk for developing pressure injuries but did not have any unhealed pressure injuries. The Care Plan dated 4/17/24 included a new skin injury to the left second toe. Clinical record review showed staff notified the PCP of a new skin impairment on 4/2/24, which was classified as a deep tissue injury (DTI). Orders received from the PCP were to Monitor left 2nd toe. Notify PCP if worsens. Staff completed weekly assessments to the area…

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, record review and interviews the facility failed to properly use a mechanical lift, low bed positions and ensure proper footwear and gait belt used to avoid hazards and prevent accidents for 3 of 21 residents reviewed, (Resident #6, #63 and #74). The facility reported a census of 68 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented the Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS showed Resident #6 dependent on staff for transfers from bed to chair. The MDS diagnoses included hemiplegia, cerebral vascular disease, and muscle weakness. Review of the Care Plan last revised on 5/16/24 for Resident #6 identified the facility failed to update the care plan to reflect the use of a mechanical lift for transfers. Observation on 6/4/24 at 3:10 PM revealed Staff A, Certified Nurse's Aide (CNA), and Staff C, CNA used a mechanical lift to transfer Resident #6 from the bed to 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 interview, the facility failed to update and liberalize a diet order, as discussed during a Standards of Care meeting (SOC) to improve nutritional intake, for 1 of 1 residents reviewed (Resident #66). The facility reported a census of 68. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #66 had a Brief Interview for Mental Status (BIMS) of 5 indicating a severe cognitive impairment. The MDS noted Resident #66 as having a one stage 2 pressure injury. Resident #66's Care Plan noted the pressure injury as well chronic pain and a dementia diagnosis. For diabetes management, Resident #66 was care planned for a control carb small portion diet. Clinical record review indicated the physician ordered a regular diet with small portions upon facility admission on [DATE] due to a diabetes diagnosis. A nutritional supplement was initiated due to pressure ulcers and trending sub-optimal appetite. The Registered Dietitian (RD) documented a significant weight loss at…

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, policy review, and staff interview, the facility failed to follow the prescribed oxygen order for 1 of 2 residents reviewed, (Resident #16). The facility reported a census of 68. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) of 12 indicating a moderate cognitive impairment. The MDS classified Resident #16 as having medically complex conditions, which include chronic kidney disease, heart failure, and respiratory failure. The use of respiratory/oxygen therapy identified but zero days listed as the number of days the therapy was administered for at least 15 minutes within the seven-day reporting period. Resident #16's Care Plan was updated on 5/2/24 and included a new focus for chronic respiratory failure. Interventions included administering oxygen as ordered, monitor for signs/symptoms of respiratory distress, report to the physician as needed, and the use of oxygen at 1-5 liters per nasal…

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

Based on staff documentation, staff interview, policy review, and observations, the facility failed to ensure the blade on the manual can opener in the kitchen was clean and free of residue to reduce the risk of bacteria growth and cross contamination. The facility reported a census of 68 residents. Findings include: The blade on the manual can opener was assessed on 6/3/24 during the initial kitchen tour. It was a blackish color with a small to moderate amount of residue. The blade was assessed again on 6/5/24 and found to be in the same condition. The Certified Dietary Manager was alerted and the entire arm of the can opener, which included the blade, was put through the dish machine to be cleaned. The blade was visible cleaner afterwards with no signs of residue. The Certified Dietary Manager (CDM) and the Registered Dietitian (RD) were interviewed on 6/5/24 at 12:30 pm. Documented daily cleaning schedule logs for May '24 and Jun '24 show the can open was checked off as cleaned. The CDM and RD both explained the employee wiped down the top and sides of the can opener arm but did…

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, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene after catheter care and medication administration for 2 of 21 residents reviewed, (Resident #21 and #74). The facility reported a census of 68 residents. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #74 documented the Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. The MDS showed Resident #74 used a walker and wheelchair for mobility and required partial or moderate assistance for bed to chair transfers. The MDS diagnoses included dementia, heart failure and renal insufficiency. Observation on 6/4/24 at 3:05 PM of Resident #74 showed Staff A, Certified Nursing Assistant (CNA) applied personal protective equipment including goggles, gown, mask and gloves. Staff A cleansed Resident #74 ' s groin folds, penis, and catheter tubing. Staff A then removed soiled gloves, discarded gloves, and failed to perform hand hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record and policy review, the facility failed to provide professional standards of care by following physician ordered wound treatment for 1 of 4 residents reviewed (Resident #24). The facility reported a census of 70 residents. Findings include: According to the MDS dated [DATE], Resident #24 had a BIMS score of 14 (intact cognitive ability). She was totally dependent on staff for toileting, lower body dressing and bathing. Her skin conditions included Moisture Associated Skin Damage (MASD) and she was on diuretic therapy related to edema. Diagnoses included heart failure, chronic kidney disease, metabolic encephalopathy. The Care Plan updated on 1/17/24 indicated that staff were to monitor her legs for skin changes and report to the nurse. She required 2 staff for bed mobility and used a bedpan for bowel movements. She was at risk for potential infection related to an indwelling catheter. Staff were directed to use enhanced barrier precautions when performing high-contact care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to reposition residents according to their needs for 2 of 3 residents reviewed (Resident #2 & Resident #15). The facility reported a census of 70 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #2 was unable to participate in a Brief Interview for Mental Status (BIMS) assessment, indicating that she was rarely/never understood. The resident had a pressure ulcer/injury over a bony prominence. His diagnoses included: Peripheral Vascular Disease, renal insufficiency, arthritis, osteoporosis, and Alzheimer's Disease. The Care Plan revised on 2/15/23 showed that Resident #2 had a history of a stroke and was nonverbal. She did not ambulate and required 2 staff assistance for bed mobility. She was at risk for pressure ulcers, staff were to monitor the sacrum after cares and ensure that the dressing was in place. A review of the Orders tab in the electronic medical record showed an order dated 3/25/24…

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 observations, interview, and record review the facility failed to use adequate infection control measures to mitigate the spread of pathogens for 2 of 4 residents reviewed (Resident #5 and Resident #24). The facility reported a census of 70 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident had functional limitations in range of motion and used a wheel chair. Resident #5 was totally dependent on staff for sit to stand, transfers, toilet transfer, and she had an indwelling catheter. The Care Plan updated on 4/23/24, indicated that Resident #5 had skin and soft tissue cellulitis infection on her leg. Staff were directed to administer medications and treatments as ordered. The resident was at risk for potential infection related to indwelling catheter and chronic wounds, staff were to use enhanced barrier precautions when performing high-contact care activities.…

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 facility personnel record review, resident, and staff interviews, the facility failed to consistently answer call lights within a reasonable amount of time (defined as 15 minutes or less). Residents reported they had to wait over 15 minutes for someone to answer their call light for 6 out 6 residents reviewed (Residents #17, #18, #19, #20, #21, #22). Findings included: The Grievance/Investigation Form dated 12/6/23 completed for Resident #20 by a staff member documented the following: On 11/29/23 Resident #20 turned on the call light at 6:15 PM. At 7:00 PM Resident #20's daughter went to the nurses' station to ask for help. The nurse told her they were in the middle of report, they didn't have time. The Grievance/Investigation Form dated 12/10/23 completed by Resident #21 reported the staff left her on the toilet from 5:00 AM to 9:30 AM. Resident #21 explained the staff told her, he needed assistance from another person to get her up. The Grievance/Investigation Form dated 1/16/24 completed for Resident #18 by a staff member indicated he had a concern with call light times.…

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 facility record review, the facility failed to sustain an effective quality assurance and performance improvement plan (QAPI) program in place to assist in the provision of quality care for residents. The facility identified a census of 78 residents. Findings included: Per the Iowa Department of Inspections, Appeals, and Licensing (IDIAL) website reflect survey results for 3/30/23. The facility received the following violations on their recertification visits: a. F550 Resident Rights/Exercise of Rights b. F658 Services Provided Meet Professional Standards c. F677 ADL Care Provided for Dependent Residents d. F684 Quality of Care e. F689 Free of Accident Hazards/Supervision/Devices f. F695 Respiratory /Tracheostomy Care and Suctioning g. F725 Sufficient Nursing Staff h. F804 Nutritive Value/Appear, Palatable/Prefer Temp i. F809 Frequency of Meals/Snacks at Bedtime j. F812 Food Procurement, Store/Prepare/Serve-Sanitary k. F842 Resident Records - Identifiable Information Per the IDIAL website the survey results dated 10/24/23 listed the repeated violations that occurred on 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, infection control policy, clinical record review and staff interview, the facility failed to complete hand hygiene while providing incontinence care for 2 of 3 residents observed. In addition, the facility failed to pass food in a sanitary manner. The facility reported a total census of 78 residents. Findings include: 1. Observation on 2/21/24 at 11:51 AM, of Staff I, Certified Nursing Assistant (CNA), and Staff J, Certified Medication Assistant (CMA), assisted Resident #14 with perineal care. Staff J performed hand hygiene and applied clean gloves. Staff J with gloves on took out a package of wipes and laid them on the bed, while they wore the same gloves, she moved the bed out to be able to get behind to assist Staff I. Without hand hygiene or applying new gloves, Staff J removed Resident #14's the pillow from under her legs, then opened the closet, removed a clean pair of shorts, and then closed the closet doors. Without hand hygiene or changing their gloves, Staff J rolled Resident #14 to her side by putting one hand on her shoulder and on her right hip…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On [DATE] at 11:51 AM, observed Staff I, Certified Nursing Assistant (CNA), and Staff J, Certified Medication Assistant (CMA), assist Resident #14 with perineal care. At the start of the observation noted the curtain open approximately 15 inches. The curtain remained open during the entire observation. Interview on [DATE] at 1:19 PM, Resident #14 revealed she didn't even notice the curtain open. Resident #14 revealed it happened all the time and she has gotten used to it. The Resident Rights policy revised [DATE] instructed employees to treat all residents with kindness, respect and dignity. The policy continues federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's rights to privacy. 3. Interview on [DATE] at 3:46 PM, Resident #15 said she would like to have 3 baths a week. Resident #15 reported she has asked the facility several times to have 3 baths a week and the facility told her she couldn't have 3 baths a week without a doctor's order.…

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 notify the physician the resident continued to refuse supplements, resulting in a continued to lose weight for 1 of the 3 residents reviewed (Residents #5). Findings include: The Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. The MDS included diagnoses of cancer, anemia, need for assistance with personal care. The SPN - Dietary Note dated 5/3/23 at 10:28 AM, indicated Resident #5 had a significant weight loss of 5.8% since admission, but weight remains appropriate. Resident #5 didn't take supplements at that time. The facility notified the primary care provider (PCP) on Resident #5's weight loss and recommended to start 206 juice 180 cubic centimeters (cc) daily. The Encounter Note dated 5/10/23 indicated the PCP saw Resident #5. She had a low body mass index (BMI) of 29.6, with a reduction of 5.8% of her weight. Start on 180 cc of a juice…

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 facility record review, family and staff interviews and policy review the facility failed to ensure people could file a grievance form without fear. In addition, the facility failed to follow-up on all grievances. Findings include: During a confidential interview on 2/20/24 at 3:04 PM, a former resident's family member (FM) explained she had a concern that her mother didn't get a bath. The FM reported she told the facility staff her family member didn't receive her bath and the facility staff told her they didn't have enough staff to give her the bath. The family member added she filled out a grievance form in November 2023 while visiting the facility. She voiced concerns about being afraid if the staff saw her put the grievance form in the box, they would take it out of the box. She explained that during that time she watched to make sure no staff watched her when she placed the grievance into the box. She explained the facility never called her or followed up with her on that grievance. She explained that during her family members time there she had filed other…

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), 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 1 resident (Resident #1) reviewed for PASRR requirements. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment. The MDS included diagnoses of Parkinson's Disease, repeated falls, need for assistance with personal care. The MDS lacked psychiatric or mood disorders. Resident #1's PASRR Level 1 dated 11/16/22 listed a Notice of no PASRR Level II required. The PASRR Level I screen remains valid for their stay at the nursing facility and should be transferred with them if they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and staff interview the facility failed to revise a resident's Care Plan to include appropriate interventions for a cognitively impaired resident to prevent repeated falls and injuries for 1 out of 3 residents reviewed (Resident #6). Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6's cognitive skills for daily decision making as moderately impaired. The MDS included diagnoses of Parkinson's Disease, dysphagia (difficulty swallowing), altered mental status, and repeated falls. Resident #6's Incident Reports from a look back period starting 8/20/23 reflected she fell 38 times. Resident #6's Incident Reports reflected the following predisposing factors for falls: a. 9/16/23 at 10:15 PM: gait imbalance, weakness, ambulating without assist b. 9/18/23 at 8:15 PM: confused, impaired memory c. 9/18/23 at 9:21 PM: confused, impaired memory d. 9/18/23 at 9:35 PM: confused, impaired memory e. 9/25/23 at 11:00 PM: confused f.…

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 pass medications as ordered by the physician for 2 of 21 residents reviewed (Resident #5 and #11). Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. The MDS included diagnoses of cancer, anemia (low blood iron), need for assistance with personal care. The Incident, Accident, Unusual Occurrence Note dated 11/6/23 at 6:34 AM, indicated that Resident #5 didn't receive her night dose of tramadol. While completing the morning narcotic count, the staff saw the scheduled tramadol signed off but not punched out of the medication card for bedtime. Resident #5 rested quietly and denied complaints. Resident #5's November 2023 Medication Administration Record (MAR) include an order dated 5/22/23 for tramadol 50 milligrams (MG) tablet. Give 0.5 tablet by mouth 2 times a day for pain. - The MAR included documentation indicating…

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 interview, staff interview, and facility policy review the facility failed to give a bath twice a week and/or per the resident's preference for 3 of 3 residents reviewed for bathing (Resident #3, #7 and #9). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score not completed. Resident #3 required supervision or touching assistance for tub or shower transfer and substantial assistance with showering or bathing self. The MDS included diagnoses of hypertension (high blood pressure), morbid obesity due to excess calories (extremely overweight), and chronic kidney disease. Interview on 2/27/24 at 12:27 PM, Resident #3 reported he didn't get his 3 baths a week and he missed baths consistently. Resident #3's Care Plan included an Intervention dated 8/7/23 to give him a bath 3 times a week. Resident #3's Task List indicated he received a shower and bathed himself on Tuesdays and Fridays. Resident #3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy the facility failed to complete assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff failed to complete vital signs and neurological assessments for 1 out 3 residents reviewed for falls (Resident#6). Findings included: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6's cognitive skills for daily decision making as moderately impaired. The MDS included diagnoses of Parkinson's Disease, dysphagia (difficulty swallowing), altered mental status, and repeated falls. Resident #6's Incident Reports from a look back period starting 8/20/23 reflected she fell 38 times. The review of Resident #6's clinical record and Incident Reports reflected the facility failed to complete vital sign assessments for the following falls: a. 9/7/23 at 10:42 AM b. 9/13/23 at 3:49 PM c. 9/18/23 at 9:20 PM d. 9/18/23 at 9:35 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 interviews and record review, the facility failed to provide a restorative program to a resident with mobility concerns for 1 of 3 residents reviewed (Residents #7). Findings include: The Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score not completed. Resident #7 is dependent on staff for tub or shower transfers and is dependent on staff for showering or bathing self. The MDS included diagnoses of Alzheimer's Disease, aphasia (loss of ability to understand or express speech), and need for assistance with personal care. Review of Resident #7's Care Plan lacked information regarding range of motion. The Follow Up Question Report for the dates of 12/1/23 - 12/31/23 directed staff to provide Resident #7 restorative of passive range of motion (PROM) to her bilateral upper extremities (BUE) and bilateral lower extremities (BLE) exercises 7 times a week. - The form listed the response on 12/6/23 and 12/14/23 as not applicable - The form lacked…

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 observations, resident record reviews and interviews the facility failed to prevent pain during medical procedures for 1 out of 1 resident (Resident #13) reviewed. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score not completed. The MDS included diagnoses of coronary artery disease (decreased blood flow due to the heart caused by a buildup in the arteries), heart failure, diabetes mellitus, and depression. Interview on 2/21/24 at 10:37 AM, Resident #13 explained someone changed his catheter recently, but didn't remember the exact date. Resident #13 described Staff EE, Licensed Practical Nurse (LPN) as horrible. He explained during the procedure he had the worst pain he ever had in his entire life. Resident #13 explained Staff EE inserted the catheter and when they started to inflate the balloon he started having pain. Resident #13 told Staff EE to stop, but they continued to inflate the balloon 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 and staff interview, the facility failed to ensure a resident had an adequate diagnosis for psychotropic medications for 1 of 3 resident's reviewed (Resident #1). Findings included: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS included diagnoses of cancer, Parkinson's Disease and repeated falls. Resident #1's Medical Diagnosis list, listed the principal diagnosis of Parkinson's Disease. The list lacked diagnoses related to mental health disorders. The untitled physician notification dated 3/26/23 indicated someone from the facility notified Staff W, Nurse Practitioner, Certified (NP-C), they found Resident #1 on the floor in his room. The situation appeared as Resident #1 slid out of his recliner. He suffered a 0.5-centimeter (cm) laceration to the top of his head. Staff W responded with an order for Zyprexa (olanzapine) 5 milligrams (mg) 1 tab by mouth.…

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, facility policy, Medline Plus, and staff interview, the facility failed to administer medications in the correct form and 1 hour or more before a meal for 1 of 7 residents reviewed (Resident #16). Findings include: During an observation on 2/22/24 at 9:30 AM, Staff A, Licensed Practical Nurse (LPN), reported Resident #16 had an order to crush medications. Staff A crushed the medications and administered them to Resident #16 with chocolate pudding as he sat in the dining room eating breakfast. Resident #16 received the following medications: a. Bumex (treats excess fluid in the body) 1 milligram (mg). b. Ferrous Sulfate (iron supplement) 325 mg. c. Levothyroxine (treats underactive thyroid) 225 mg. The Clinical Record lacked an order to crush Resident #16's medications or he could receive his levothyroxine 1 hour or less before his meal. The Federal government web site, https://medlineplus.gov/druginfo/meds/a682461.html, revised 2/15/19 and accessed 2/22/24 included the following instructions for the use of levothyroxine: a. Take levothyroxine…

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, facility record, pharmacy record, and staff interviews, the facility failed to keep narcotic medication secure to prevent diversion. The facility reported 78 residents. Findings include: 1. In a concurrent interview and observation on 2/22/24 at 11:10 AM, the medication cart contained a drawer containing glucometer (blood sugar testing) equipment with 3 orange medication tablets lying next to an empty clear disposable medication cup. Staff A, Licensed Practical Nurse (LPN), reported that she will dispose of the 3 orange medication tablets immediately and placed them in the sharp's container on the medication cart. The Storage of Medications Policy dated November 2020 directed the following: a. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. b. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. In an interview on 2/22/24 at 11:10 AM, when asked if it was acceptable that loose medication tablets be stored in 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 reviews, facility policy review, resident, staff, and medical facility interviews, the facility failed to ensure 2 out of 2 residents reviewed (Resident #3 and Resident #13) received transportation to their appointments, causing them to have to be rescheduled. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score not completed. The MDS included diagnoses of hypertension (high blood pressure), morbid obesity due to excess calories and chronic kidney disease. Interview on 2/17/24 at 12:27 PM, Resident #3 explained he had an appointment scheduled for that day, but it got rescheduled until next week. Resident #3 explained he didn't know they changed his appointment time, but it frustrated him as he had things that he liked to get done but it seemed he had issues with his ride a lot. There are a lot of times when they have to reschedule his appointment due to rides. The facility told him the Veterans Administration (VA) is…

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, interviews, facility policy and procedures, the facility failed to provide adequate transfers for 2 out of 3 residents observed to ensure a safe transfer according to the facility policy (Resident #17 and Resident #20). The facility also failed to implement effective interventions to prevent multiple falls involving a wheelchair and self-transfer for 1 out of 3 residents reviewed (Resident #13). Findings included: 1. Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #17 required assistance of two persons for transfers, toilet use, and personal hygiene. The MDS included diagnoses of a fracture of the right ankle and polyneuropathy (damage to multiple nerves of the peripherals). The assessment reflected that Resident #17 fell in the previous month and six months before her admission to the facility. The Physician's Order dated 9/27/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, and staff interviews, the facility failed to provide enough staff to meet the needs of the residents who resided in the facility for 4 out of 8 residents reviewed (Residents #3, #4, #9, and #10). Residents reported that the staff could not answer their call light within 15 minutes due to the lack of staff. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #3 required limited assistance of one staff for bed mobility, transfers, dressing, and personal hygiene, and extensive assistance for toileting. The MDS included diagnoses of stroke, left side paralysis, seizure disorder, anxiety disorder, depression, bipolar disorder (mental health disorder affecting mood) and Post-Traumatic Stress Disorder (PTSD). In an interview on 10/10/23 at 10:30 AM Resident #3 stated that call light response times were a problem. He stated that the night before…

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 facility record and policy review, and resident, staff, and pharmacy interview, the facility failed to obtain and provide routine and emergency drugs for 4 out of 4 residents reviewed (Residents #3, #4, #8, and #9). The facility reported a census of 81 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #3 required limited assistance of one staff for bed mobility, transfers, dressing, and personal hygiene, and extensive assistance for toileting. The MDS included diagnoses of stroke, left side paralysis, seizure disorder, anxiety disorder, depression, bipolar disorder (mental health disorder affecting mood) and Post-Traumatic Stress Disorder (PTSD). In an interview on 10/10/23 at 10:30 AM, Resident #3 stated that the facility had ran out of some of his medications several times and he has had to go without. Resident #3's June 2023…

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, facility policy, resident and staff interviews, the facility failed to ensure food preferences were honored for 5 out of 7 residents (Residents #3, #4, #8, #9 & #23). This deficient practice had the potential to result in decreased intake for the residents. The facility reported a census of 81 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. In an interview on 10/10/23 at 10:30 AM, Resident #3 stated that if you don't like what you are served at meals, you don't eat. He stated that they used to get a menu to choose from, but the facility stopped doing it that way. He reported that residents were told that October 1st they would be able to choose what they wanted again, but it hasn't happened. The chart review revealed Resident #3 the following weights a. 5/29/23, 322.8 pounds b. 10/1/23, 287.0 pounds c. 10/23/23, 280.0 pounds which is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview, facility identified meal times and facility policy review, the facility failed to meet the resident's preferences regarding meal times for 4 out 6 residents reviewed (Residents #3, #9, and #23). In addition, the facility failed to provide afternoon and bedtime snacks on a routine basis. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. In an interview on 10/10/23 at 10:30 AM, Resident #3 stated that he eats in his room per his preference. He stated meal times are 8:00 AM, 12:00 PM, and 5:00 PM. He stated that many times he doesn't get his lunch until 1-1:30 PM and supper 7-7:30 PM. On 10/11/23 at 10:10 AM observed a paper with meal times posted in the dining room by the kitchen door. The times listed breakfast at 7:30 AM, lunch at 12:00 PM, and supper at 5:30 PM. In an interview on 10/18/23 at 4:15 PM, Resident #3 reported that 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 observation, and facility policy review, the facility failed to display respect and dignity for 1 out of 3 residents (#22) who required assistance with eating. Findings include: 1. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified the presence of short and long-term memory impairment. The MDS indicated that Resident #22 required extensive assistance of two or more persons with bed mobility, transfers, dressing, eating, personal hygiene, and toilet use. The MDS also indicated that Resident #22 could not ambulate or propel her wheelchair. The MDS included diagnoses of severe unspecified dementia, dependence on wheelchair, need for assistance with personal care, cognitive communication deficit, anxiety disorder, Parkinson's disease, Alzheimer's disease, aphasia (difficulty speaking), and right sided hemiplegia (paralysis). Resident #22's Care Plan Focus revised 2/15/23 listed that she had a history of a stroke and did not speak. Resident #22's Care Plan Focus dated 5/12/23 reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to notify the physician of a significant change in condition and when a resident refused to follow physician orders for 1 of 3 residents reviewed (Resident #6). The facility failed to report the following: 1. Notify the Physician of a weight gain of 3 pounds in one day. 2. Notify the Physician when Resident #6 refused to wear TED hose (specialized stockings to prevent clots and swelling). 3. Notify the Physician when Resident #6 refused to wear CPAP machine (Continuous Positive Airway Pressure) (machine used to keep airways open while asleep) Findings include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #6 required supervision and assistance from one person with transfers and supervision. In addition, she required assistance from two persons with bed mobility and toilet use. The MDS…

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, policy review, and resident and staff interviews, the facility failed to meet professional standards by failing to administer medications as prescribed by the physician for 3 out of 5 residents reviewed (Residents #3, #6, and #8). The facility reported a census of 81 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed diagnoses of seizure disorder, anxiety disorder, depression, bipolar disorder and Post Traumatic Stress Disorder (PTSD). In an interview on 10/10/23 at 10:30 AM, Resident #3 stated that he often received his medications late. He stated medication times are 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Resident reported that over the weekend he received his 4:00 PM medication at 7:30 PM. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS also revealed diagnoses 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 facility chart review, resident and staff interview, and policy review, the facility continued to fail to provide bathing or showering per resident preference for 1 of 7 residents reviewed (Residents #4). Findings include: Resident #4's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS also revealed the resident needed limited assistance of one staff member for bed mobility, transfer, dressing, toilet use, and personal hygiene. It further revealed diagnoses of cancer, coronary artery disease, heart failure, diabetes, anxiety disorder, depression, and asthma. In an interview on 10/10/23 at 1:50 PM, Resident #4 stated that he is often skipped on bath days. He stated he was supposed to get a whirlpool bath this morning right after breakfast, but they brought him back to his room instead. He stated that this is not the first time it's happened. Facility record review of Tasks revealed that resident's preferred bathing days were Tuesday and Friday. Review 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, staff interviews, and policy review the facility failed to assess and provide interventions necessary for the care and services, to maintain the residents' highest practical physical well-being for 2 of 4 residents reviewed (Residents #6, #13). The facility failed to assess/document skin impairments for Resident #6 and a fall for Resident #13. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #6 required supervision and assistance from one person with transfers and supervision. In addition, she required assistance from two persons with bed mobility and toilet use. The MDS identified ambulation in the room or the hallway did not occur during the assessment period. The MDS included diagnoses of anemia (low iron in the blood), heart failure (impaired pumping of the heart causing an overload of fluid), hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, observations and policy review, the facility failed to provide appropriate oxygen services for 2 of 4 resident (Residents #6, #11) reviewed for respiratory services. The facility reported a census of 81 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #6 required supervision and assistance of one person with transfers and supervision and assistance of two with bed mobility and toileting. The MDS identified ambulation in the room or the hallway did not occur during the assessment period. The MDS included diagnoses of anemia, heart failure, hypertension, renal failure, diabetes mellitus, depression, chronic lung disease, respiratory failure and morbid obesity. The MDS identified Resident #6 was receiving oxygen therapy while a resident at the facility. The July 2023 Medication…

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, facility policy, and procedures, resident and staff interviews, the facility failed to identify, intervene and alleviate physical pain in a timely manner for 1 out of 2 residents reviewed for neglect (Resident #18). Findings included: 1. Resident #18's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date to the facility as 10/12/23 from a short-term general hospital. The Care Plan dated 10/12/23 reflected that Resident #18 suffered from acute pain related to shingles (otherwise known as herpes simplex). The Interventions instructed staff to anticipate the need for pain relief and respond immediately to any complaint of pain. In addition, the Interventions instructed the staff to monitor, document, and report to the nurse as needed with complaints of pain or requests of pain management. Resident #18's October 2023 Medication Administration Record (MAR) included the following orders dated 10/12/23: a. Valacyclovir 1 gram tablet ordered daily for herpes simplex.…

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, clinic record review, and policy review, the facility failed to administer insulin medication appropriately for 1 out of 8 residents (Resident #4) reviewed. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS indicated Resident #4 required limited assistance of one person with bed mobility and toilet use. The MDS identified Resident #4 required supervision and assistance of one person with transfers. The MDS included diagnoses of cancer, heart failure (heart doesn't pump blood effectively causing a buildup of fluid in the body), hypertension (high blood pressure), renal disease (kidney), and diabetes mellitus. The MDS identified Resident #4 received insulin injections for seven out of seven days in the lookback period. Resident #4's September 2023 Medication Administration Record (MAR) included an order dated 8/8/23 for Novolog (rapid acting insulin) 100…

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 reviews, resident, staff, and medical facility interviews, the facility failed to ensure 3 out of 3 residents reviewed, (Residents #3, #10, and #14) received transportation to their appointments, causing them to have to be rescheduled. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #3 required limited assistance of one person for bed mobility, transfers, dressing, and personal hygiene, and extensive assistance for toilet use. The MDS included diagnoses of stroke, left side paralysis, seizure disorder, anxiety disorder, depression, bipolar disorder, and Post-Traumatic Stress Disorder (PTSD). In an interview on 10/10/23 at 10:30 AM, Resident #3 stated he has missed several Veterans Administration (VA) appointments as well as chiropractic and massage appointments. He stated the facility told him that VA was responsible for his…

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 documentation and interview, and staff interview, the facility failed to provide food that was palatable, appetizing, and attractive to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 81 residents. Findings include: Resident #10's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderate cognitive impairment. In an interview on 10/10/23 at 3:15 PM, Resident #10 stated that the food left a lot to be desired. He stated that he recently ate a salad and lifted the plate closer to his mouth when he felt something on the bottom of the plate. He stated that he looked under the plate and found dried food debris stuck to it. He reported that for a recent lunch they served him a hot dog on a plate with cottage cheese and pork and beans. Resident #10 produced a picture from his cell phone of the plate showing the hot dog bun sitting in a large pool of pork and bean juice as well as the cottage cheese and beans running together. He also provided a picture 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 facility policy review, observations, resident, and staff interviews, the facility failed to provide fresh ice water for 3 out 7 residents reviewed for hydration (Residents #3, #9, and #10). Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. In an interview on 10/18/23 at 4:15 PM, Resident #3 reported that it is hit or miss as to whether the staff bring fresh water around. An observation revealed Resident #3's cup sitting on the dresser and it did not appear to have ice in it. 2. Resident #9's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. In an interview on 10/18/23 at 4:10 PM, Resident #9 stated that she does not get fresh water unless she asked for it. The observation of the facility cup on the overbed table appeared to have no ice in it. 3. Resident #10's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderate…

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 and documentation, and staff interview, the facility failed to follow proper sanitation practices to prevent the outbreak of foodborne illness for 1 of 1 residents reviewed (Resident #10). The facility reported a census of 81 residents. Findings include: Resident #10's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderate cognitive impairment. In an interview on 10/10/23 at 3:15 PM, Resident #10 provided a picture he took on his cell phone of a plate salad provide by the facility. Resident #10 stated that he picked up the plate to get it closer to his mouth when he felt something on the bottom of the plate. The picture showed food debris on the bottom of the plate which appeared to be possibly a deck of card sized piece of pancake with splotches of something red surrounding it. In an interview on 10/11/23 at 11:40 AM, Resident #10 also stated that he recently found a hair in his taco, but didn't take a picture of it. In an interview with the Administrator on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and representative interviews, the facility failed maintain an accurate and complete resident clinical records for resident's personal possession for 1 out of 3 resident's reviewed (Residents #7 and #17). In addition, the facility failed to maintain an accurate and complete record related to a resident falling out of his wheelchair for 1 out of 3 resident's reviewed (Resident #13). Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. In an interview on 10/11/23 at 12:50 AM, Resident #7's Representative reported that the facility failed to give Resident #7 all of her personal possessions upon discharge. Resident #7's clinical record lacked a personal possession inventory record on file for admission or discharge. 2. Resident #17's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact…

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.