Karen Acres Care Center

Based on clinical record review, hospital record review, family and staff interviews, and facility protocol review, it was found that for 1 of 4 residents reviewed for assessment and intervention (Res #3), the facility failed to complete accurate daily assessments; transcribe and administer medications per provider orders; recognize and assess a change in bowel patterns; follow the facility protocol for a bowel regimen; and completely and accurately document fluid intake for a resident on a fluid restriction. The facility reported a census of 29. Findings include:The Minimum Data Set (MDS) Assessment of Resident #3 dated 1/30/26 identified a Brief Interview for Mental Status (BIMS) score of 13 which indicated cognition intact. The MDS reflected the resident to be frequently incontinent of bowel. The MDS documented diagnoses which included heart failure and constipation. The MDS recorded the resident experienced pain during the 5-day look back period and received scheduled and as needed pain medications as well as non-medication pain interventions. The MDS recorded the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review, the facility failed to follow the Care Plan for proper and safe transfer for 1 of 4 residents reviewed, Due to Resident's (Resident #3) increased weakness Resident #3 had to be lowered to the floor during attempted improper transfer. The facility reported a census of 31 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], documented Resident #3 with a Brief Interview for Mental Status (BIMS) of 13, indicating cognitively intact, with diagnoses including Atrial Fibrillation, Hypertension, Diabetes Mellitus, Thyroid Disorder, Osteoarthritis, Cervical Spinal Stenosis (narrowing of spinal canal, causing pressure on the spinal cord and nerves to the neck region of the spine), Bipolar Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). Review of Care Plan revised on 9/2/25 revealed Resident #3 has an Activities of Daily Living (ADL) self-care deficit with interventions including all transfers with use…

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

Based on observations, clinical record review, staff interview, and facility policy review, the facility failed to follow the Care Plan for proper and safe transfer for 1 of 1 residents reviewed, resulting in a fall (Resident #27). The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) Assessment of Resident #27 dated 3/5/25 identified a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented the resident had suffered no falls since the last assessment. The Care Plan, last reviewed 6/9/25, identified a Focus Area of Activities of Daily Living (ADL) Self Care Performance. The Care Plan directed staff that Resident #27 required assistance with transfers, and ambulation with a gait belt (a belt worn around the resident's waist to assist the caregiver to provide support and stability) and a walker. The Care Plan identified an additional Focus Area of high risk for falls related to history of frequent falls. Resident #27 score 75 on the Morse Fall Scale (a clinical tool used to assess a resident's risk 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 observations, staff interviews and facility policy review, the facility failed to maintain uncluttered hallways to promote a safe and homelike environment for one of three hallways. The facility also used a shower room for equipment storage. The facility reported a resident census of twenty eight. Findings include: On 7/5/24 at 9:50 am, the 300 Hallway was noted to be very cluttered. One full side of the hallway had multiple wheelchairs, full body and standing mechanical lifts and a dining chair. On the opposite side of the hall, one room had an isolation cart outside of the doorway. The doorway to room [ROOM NUMBER], room of Resident #22, was noted to be partially obstructed by the wheels of a wheelchair. The Minimum Data Set of Resident #22, dated 6/19/24 documented the resident needed supervision or touching assistance for wheelchair locomotion up to 150 feet. On 7/7/24 at 9:22 am, the Director of Therapy stated Resident #22 generally had a staff member assist him when propelling his wheelchair but…

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, menu review, and staff interview, the facility failed to serve the appropriate menu for two of two meals observed. The facility also failed to follow a standard pureed process for two of two pureed food prep observations. Findings include: The facility's menu for lunch on 7/6/24 identified the following items to be served to diets. #6 Scoop (sc) Tator tot casserole 8 ounces (oz) Serving Toss salad/dressing 4 oz Serving chilled fruit 1 each bread/[NAME] 1 Square (SQ) Smores Brownies 8 oz Milk Continuous observation of lunch preparation and service began on 7/6/24 at 10:50 AM. Staff E, Cook, placed two 4 oz servings of tator tot casserole into the blender. She blended the casserole. When done with the puree process, Staff used spatula, placed servings into clean pan, and placed into oven. No measurement of the volume of pureed casserole was done. Staff E stated she placed two servings of peaches in bowl which was prepared prior to observation beginning. She placed the peaches in the blender.…

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

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing resident food. The facility reported a census of 27 residents. Findings include: On 7/05/24 at 7:30 AM, a kitchen observation identified the following findings: A True refrigerator contained: 1) An undated, previously opened jar of mayonnaise. 2) An unlabeled bowl of meat and vegetables. 3) An unlabeled, undated tub of a chopped orange item. 4) An unlabeled, undated, and partially uncovered bowl of chopped cantaloupe. 5) An unlabeled, undated tub of a shredded orange item. A True freezer contained: 1) An unlabeled, undated bag of meat. 2) An unlabeled, undated block of meat wrapped in Saran wrap. A shelf located in the kitchen contained an undated, previously opened jar of peanut butter. On 7/07/24 at 10:08 AM, the Administrator stated food should be labeled, dated, and covered when stored. A policy titled Dining Services Storage dated June 2018 indicated foods held in refrigerator or other storage areas shall be appropriately covered,…

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 clinical record, staff and family interviews, policy review and video evidence, the facility failed to protect a resident from abuse when a certified nursing assistant utilized a personal smartphone to video record a resident (Resident #4) and distribute the recording on a social media site and labeled the video with the resident's name. The facility reported a census of 28 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident#4 revealed a diagnosis of dementia, depression, anxiety and chronic kidney disease and required the assistance of staff for personal hygiene, toileting and dressing needs. The Brief Interview for Mental Status (BIMS) score of 10 which suggested a moderate cognitive impairment and disorganized thinking with difficulty keeping track of what is being said. The Care Plan directed staff to monitor, document, and report a change in behavior, mood and cognition to include hallucinations and delusions, social isolation, suicidal thoughts,…

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 interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination of invasive medical equipment for one of one blood glucose test observations. Facility staff also failed to decrease possible spread of infection for one of one resident reviewed for a urinary catheter (Resident#28) . The facility reported a census of 27 residents. Findings include: 1. On 7/05/24 at 7:22 AM, Resident #28 was observed sitting in her wheelchair with her indwelling catheter drainage bag hanging on the underside wheelchair frame and the tubing lying on the floor. On 7/5/24 at 8:31 AM, a second observation revealed the resident's indwelling catheter tubing was still lying on the floor. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of Cancer, hemiparesis (one-sided muscle…

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

Based on observation, resident and staff interviews, the facility failed to treat each resident in a dignified manner for 3 of 8 residents reviewed (Resident #2, #5 and #9). The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #2 dated 1/23/24 identified a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The MDS documented diagnoses that included Alzheimer's disease. The Care Plan of Resident #2, revision date 1/8/24 identified a focus area of Impaired Cognitive Function related to Alzheimer's disease. On 3/11/24 at 11:42 am Staff F, a staff member who requested to stay anonymous, stated that on an earlier date, she had been in the room of a resident nearby the room of Resident #2. She stated Staff D, Certified Nurse Aide (CNA) was in the room of Resident #2 providing cares to the resident. She stated she heard Staff D tell Resident #2 to shut up. She further reported she has heard staff members be rude to various residents a number of times and some of the instances have…

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

Based on observation, staff interview, and facility policy review the facility failed to store food in accordance with professional standards by not labeling foods that were open with open dates and did not practice appropriate hand hygiene by touching food and contaminated objects without hand hygiene and not changing gloves. The facility reported a census of 29 residents. Findings include: On 10/9/23 from 11:30 AM through 12:15 PM a continuous observation during the initial kitchen tour revealed: a. Dry storage had three 1 pound bags of gelatin open and undated. b. Dry storage had two 16 oz bags of chips open and undated. c. Dry storage had a 4 oz bag of corn / rice puffs open and undated. d. Dry storage had a freezer bag of cake mix open and undated. e. Dry storage had 32 oz. thickened dairy beverage open 03/08/23 open and unrefrigerated f. Dry storage had two 46 oz. thickened orange juice expiration date 2/9/23 g. Dry storage had two 46 oz. thickened orange juice expiration 8/5/23 h. Dry storage had a plastic storage container of cereal open and undated. i. Dry storage had a…

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

Based on observation, staff interviews, facility documentation and guidance from the Centers for Disease Control (CDC), the facility failed to handle a urinary catheter bag and tubing with appropriate infection control standards of practice for 1 of 1 residents reviewed (Resident #17). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) of Resident #17 dated 9/22/23 identified a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. The MDS coded the presence of an indwelling catheter. The MDS documented diagnoses that included stroke, hemiparesis (paralysis of one side of the body), urine retention, and neuromuscular dysfunction of the bladder. The Care Plan dated 10/4/23 documented the resident to have an indwelling catheter related to neurogenic bladder. Observation began on 10/11/23 at 11:28 am and included the following: -Staff A, Certified Nurse Aide (CNA) and Staff B, CNA stated they would empty the drainage bag and transfer the resident from recliner to wheelchair to go to lunch. Observed both staff members put…

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.