Southfield Wellness Community

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interview, the facility failed to correct their own deficiencies for 5 of 9 areas of concern. The facility reported a census of 55 residents.Findings include:The facility QAPI report, reviewed December 10, 2025, defined the mission as to provide resident-centered healthcare services, excellence in clinical care, and to promote caregiver engagement and empowerment to better serve the resident, family, and the community. The guiding principles included: a. QAPI outcomes are directly related to the quality of care and the quality of life of our residents. b. Our QAPI program focuses on our organization's systems and processes and we strive to continually identify and make changes to our systems/processes in order to improve outcomes.c. Our organization sets goals for performance and measures progress toward those goals. The QAPI program strives to promote safety and high quality throughout clinical interventions and service delivery while emphasizing autonomy,…

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 record review, staff interviews, and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 57 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS included diagnoses of heart failure, hypertension (high blood pressure), and traumatic brain injury. On 1/27/26 at 12:13 PM Staff A, Certified Nursing Assistant (CNA), explained the incident happened on 1/14/25 between 2:45 PM and 3:00 PM. Staff A reported as she helped Staff C, Radiology Technician, position Resident #1 for an x-ray, she observed Staff C put her gloved hand over Resident #1's mouth due to him coughing. Staff A stated Staff C asked him to stop…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility investigation, dignity policy/procedure review, resident and staff interviews, the facility failed to provide personal care to a resident incontinent of stool in a timely manner that promoted their dignity and quality of life for 1 out of 4 residents reviewed. (Resident #1). The facility identified a census of 56 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #1 could understand and other understood them with no behavior or mood issues. Resident #1 required dependent assistance with toileting hygiene and frequently incontinent of bowel. The MDS included diagnoses of hypertension (high blood pressure), neurogenic bladder (condition where nerve damage disrupts the brain-bladder communication, causing problems with storing and releasing urine), non-Alzheimer's dementia, and depression.The Care Plan with a target date of 1/17/26,…

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), document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed (Residents #1, #3, #4, and #6). The facility reported a census of 56 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 6 indicating cognitive impairment. Review of Electronic Health Record (EHR) documented Resident #1 resided in room D17.Interview on 9/30/25 at 1:30 PM Resident #1 stated the facility was short of staff on the evening shift. Resident #9 stated she had to wait longer than 15 minutes to have her call light answered. Review of document titled, Past Call Report for room number D17 documented on 9/28/25 call light was turned on at 10:37 AM and to room elapsed time of 18 minutes.2. The MDS dated [DATE] for Resident #3 documented a BIMS score of 15 for which…

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, resident, and staff interviews the facility failed to provide the residents with a comfortable homelike environment by failing to keep a resident bed in functioning order and the toilet properly maintained. The facility reported a census of 56 residents. Findings include:Observation on 9/29/25 at 11:20 a.m., revealed, the footboard in Resident #1's room, split in half with silver brackets placed on the inside holding the foot board together.Observation on 9/30/25 at 1:30 p.m., revealed the footboard in Resident #1's room, split in half with silver brackets placed on the inside holding the footboard together.Interview on 9/30/25 at 1:30 p.m., Resident #1 explained the footboard has been broken since they admitted to the facility in July and they are afraid to sleep in the bed causing the footboard to break and falling out of bed. Resident #1 also commented that their bathroom toilet was not working for a couple of days and that they had to use a commode and is embarrassed with the commode still in their room.A work order, given to the surveyor on 10/1/25 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 clinical document review, staff interview, the facility failed to ensure that each resident's medication regimen is free from unnecessary medications for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 56 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident has short term memory impairments, moderately impaired decision making abilities, substantial to maximal assistance with activities of daily living, and behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, disrobing in public, throwing or smearing food or verbal/vocal symptoms like screaming, disruptive sounds). The MDS included diagnoses of anxiety, bipolar disorder and schizophrenia. The MDS indicated 2 falls with no injury since the prior assessment, and receives antipsychotic, antianxiety and antidepressant medications that were used in the last 7 days of the look back period.The Care Plan Focus target date 8/18/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, resident and staff interviews, the facility failed to provide a professional standard of quality by not following physician orders for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 56 residents.Findings include: Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired cognitive memory, is able to be understood and understands others, with no mood or behavior issues. The MDS listed Resident #3 as dependent with toileting hygiene and had an indwelling catheter. The MDS included diagnoses of hypertension (a condition in which the force of the blood against the artery walls is too high), neurogenic bladder (a term used for urinary conditions caused by nerve problems affecting bladder control), diabetes mellitus, and multiple sclerosis.The Care Plan Target dated 11/23/25, indicated Resident #3 is at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff and resident interview, the facility failed to assess a resident that had no urinary output in their catheter bag for two days for which resulted in the resident going to the Emergency Department with discomfort (Resident #3) for 1 of 3 resident reviewed. The facility identified a census of 56 residents.Findings include:Resident #3 Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired cognitive decisions, is able to be understood and understands and no behavior or mood issues. The resident required dependent assistance for activity of daily livings (ADL) and an indwelling catheter used for urinary output. The MDS included diagnoses of neurogenic bladder, (an injury or disease that interrupts the electrical signals between your nervous system and bladder function) diabetes mellitus, pneumonia, multiple sclerosis, depression and sepsis (a life-threatening…

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 document review, resident and staff interview, the facility failed to provide adequate nursing supervision for 1 of 3 residents (Resident #4) reviewed. The facility reported a census of 56 residents. Findings include:Resident #4's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 for which indicated no impaired cognitive decisions, is able to be understood and understands and no behaviors. The resident required partial to moderate assistance with activity of daily living and had 2 falls with no injury prior to being admitted to the facility. The MDS included diagnoses of heart failure, hypertension, diabetes mellitus, Parkinsons, anxiety, and depression.The Care Plan Focus target dated 12/4/25, indicated Resident #4 is at risk for falls related to gait imbalance. Interventions include to assist resident with ambulation and transfers as needed, bed is in low position, resident to leave bedroom door open for closer…

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 review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interviews, the facility failed to correct their own deficiencies for 7 of 12 areas of concern. The facility reported a census of 54 residents. Findings include: The facility QAPI Plan reviewed 1/14/24 defined the mission as to provide resident centered healthcare services, excellence in clinical care, and to promote care giver engagement and empowerment to better serve the resident, family and the community. The guiding principles consisted of the following: QAPI has a prominent role in our management and board functions on par with monitoring reimbursement and maximizing revenue. QAPI outcomes are directly related to the quality of care and the quality of life of the residents. - The organization uses QAPI to make decisions and guide the day to day operations. QAPI included all employees, all departments and all services provided. The QAPI program focuses on our organization's systems and processes and the facility strives to continually identify and make…

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, antibiotic stewardship policy, clinical record review, and staff interview, the facility failed to follow policies with all residents. The Infection Preventionist (IP) identified residents with an infection using a facility map, but couldn't provide evidence of when the antibiotic began, the monitoring of laboratory data, and the evaluation of the treated infections. The facility had 2 residents (Residents #43 and #37) with active urinary tract infections (UTIs) and 1 resident (Resident #35) who completed an antibiotic for a methicillin resistant staphylococcus aureus (MRSA) infection (a contagious infection that requires treatment with specific medication due to the infection not responding to other medications). The facility reported a census of 54 residents. Findings include: 1. The Health Status Note dated 1/16/25 at 7:50 AM reflected Resident #37 returned form an appointment with the following new orders: a. Start Bactrim DS (antibiotic) 800 - 160 MG 1 tablet by his g-tube (tube inserted in the stomach to bypass the esophagus to prevent issues with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interview and policy review, the facility failed to provide resident bathing to maintain good personal hygiene and personal choice for residents unable to carry out the activity of daily living (ADL) independently, for four of four residents reviewed (#6, #24, #27 and #48). The facility reported a census of 54 residents. 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 indicated Resident #6 used a wheelchair and required total assistance from staff to shower/bathe. The MDS included diagnoses of progressive neurological conditions, diabetes mellitus and multiple sclerosis. The Care Plan Focus with a target date of 3/11/25 indicated Resident #6 required assistance with ADL's. The Interventions instructed the staff with the following: a. Assist Resident #6 with shower/bathing per schedule. b. Resident #6 needed total…

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 interviews, staff interview and policy review, the facility failed to provide care for 1 out of 21 residents reviewed (Resident #24) in a manner to promote dignity and respect. The facility reported a census of 54 residents. Findings include: Resident #24's Minimum Data Set (MDS) assessment dated [DATE]identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. On 2/24/25 at 11:22 AM, Resident #24 said she became incontinent of BM (bowel movement) a couple of times since she admitted to the facility, due to not having enough staff. She reported she felt like a baby when she became incontinent. On 2/26/25 at 4:00 PM, the Administrator reported she expected staff to treat residents with respect, dignity, and provide them care as soon as possible. On 2/27/25 at 8:30 AM, Resident #24 reported she knew when she needed to have a BM and became incontinent of BM a couple times recently as she waited for someone to help her. The facility policy titled Resident Rights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to develop a Care Plan to address risk factors and interventions for 1 of 21 residents reviewed (Resident #25) for comprehensive Care Plans. The facility reported a census of 54 residents. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of diabetes mellitus, non Alzheimer's dementia, depression and post-traumatic stress disorder (PTSD). The MDS documented Resident #13 received anti anxiety medication and a hypoglycemic medication during the lookback period. Resident #13's February 2025 Medication Administration Record listed the following orders: a. Metformin HCL 1000 mg (milligrams) - give 1 tablet 2 times a day for type 2 diabetes mellitus. b. Sitagliptin 100mg - give 1 tablet 1 time a day for type 2 diabetes mellitus. c. Buspirone HCL (anti anxiety medication) 10 mg -…

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, resident and staff interviews and policy review, the facility failed to provide restorative care for 2 of 2 residents reviewed (Residents #43 and #46). The facility failed to initiate a restorative program for Resident #43 for 18 days after the Physical Therapist (PT) recommended restorative care. In addition, they failed to provide restorative care as (PT) recommended for Resident #46. The facility reported a census of 54 residents. Findings include 1. Resident #43's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of a stable fractur of the thoracic spine and muscle weakness. The MDS listed Resident #43 received Physical Therapy (PT) and Occupational Therapy (OT). Resident #43's Clinical Physician Orders reviewed 2/25/25 included an order dated 1/14/25 for physical therapy to evaluate and treat. Resident #43's MDS assessment dated [DATE] a Medicare part A stay from 1/14/25 - 2/12/25. Resident #43 received 489 minutes of PT and 317 minutes of OT. A document…

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 3. Resident #27's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, anemia, hypertension, hyperlipidemia (elevated cholesterol levels increasing the risk for stroke or heart attacks) and paraplegia (the loss or impairment of motor and sensory functions in the lower half of the body). The MDS identified Resident #27 received a diuretic during the lookback period. The Care Plan Focus with a target date of [DATE], indicated Resident #27 had a risk for altered cardiovascular functioning related to hypertension. The Interventions directed the following: a. Monitor vital signs, weight and labs as ordered. b. Knee high TED hose (specialized stocking to prevent blood clots). The Care Plan Focus with a target date of [DATE] indicated Resident #27 required the use of diuretic medication related to edema. The Interventions instructed to monitor weights. The POC Response History reviewed [DATE] listed a task to apply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 2 residents reviewed (Resident #20) for falls. The facility failed to complete a thorough root cause analysis and implement a fall intervention after a fall occurred. The facility reported a census of 54 residents. Findings include: Resident #20's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. Resident #20 required substantial to maximal assistance with bed mobility and all transfers. The MDS included diagnoses of anemia (low iron levels in the blood), heart failure (inability for the heart to pump blood), hypertension (high blood pressure), diabetes mellitus, malnutrition (inadequate intake of nutrition) and non Alzheimer's disease. The MDS documented Resident #20 had one fall with injury since last assessment. The Care Plan Focus with a…

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

Based on clinical record review and staff interview, the facility failed to provide dialysis care to meet the needs of a resident for 1 of 1 residents reviewed (Resident #34). The facility failed to notify the primary care physician (PCP) of weight gain according to the parameters ordered by the PCP. The facility reported a census of 54 residents. Findings include: Resident #34's Minimum Data Set (MDS) assessment, dated 12/6/24, identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, heart failure, hyperlipidemia (elevated cholesterol increasing the risk of stroke or heart attack) and end stage renal (kidney) disease (ESRD). The MDS indicated Resident #34 received dialysis. The Care Plan with a target date of 3/16/25 included the following Focuses: a. Resident #34 required dialysis related to a diagnosis of end stage renal disease. i. The Intervention directed to monitor weights. b. Resident #34 required the use of diuretic (medication used to reduce the amount of fluid) 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, staff interviews and policy review, the facility failed to ensure the Physician responded promptly to a notification of abnormal laboratory results and chest x ray results for 1 of 21 residents (Resident #55) reviewed. See F684 for additional information regarding Resident #55. The facility reported a census of 54 residents. Findings include: Resident #55's MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 11, indicating moderately impaired cognition. Resident #55 required substantial to maximal assistance with bed mobility and all transfers. The MDS included diagnosis of heart failure (inability for the heart to pump blood), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), diabetes mellitus and acute kidney failure. The MDS documented Resident #55 received diuretic medication during the lookback period. A Progress Note dated [DATE] documented the ARNP (Advanced Registered Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident, and staff interviews, the facility staff failed to consistently answer call lights within a reasonable amount of time (15 minutes). Residents reported having to wait thirty to forty five minutes for someone to answer their call light numerous times during the week. The facility reported a census of 54 residents. Findings include: 1. Resident #46's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #46 required substantial assistance of 2 staff for transfers and toileting. The MDS included a diagnosis of hemiplegia (paralysis of one side of the body). During an interview on 2/24/25 at 12:41 PM, Resident #46 stated the staff took a long time to answer their call light. Observed Resident #46 in a wheelchair, with his left leg and left arm secured to the wheelchair arm rest. Resident #46 stated it took 30 minutes to an hour in the afternoon and evening shifts.…

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 and policy review, the facility failed to adequately trained staff to perform a treatment for 1 of 1 resident reviewed (Resident #6). The facility failed to have a nurse flush Resident #6's catheter as ordered. Instead of the nurse, a Certified Nursing Aide (CNA) the irrigated/flushed Resident #6's catheter. The facility reported a census of 54 residents. 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 included diagnoses of progressive neurological conditions, diabetes mellitus, neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage to the nerves that control it), and multiple sclerosis. The MDS identified the resident had an indwelling catheter. The Care Plan Focus with a target date of 3/11/25, indicated Resident #6 required the use of a suprapubic catheter (a thin,…

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 reviews, staff interviews, family interview, facility records, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 4 residents reviewed (Residents #1). The facility failed to follow physician orders to administer the correct dose of an antipsychotic medication for 7 days (9/20/24 to 9/27/24). The facility reported a census of 52 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #1 required supervision or touching assistance with bed mobility and transfers. The MDS included diagnoses of hypertension (high blood pressure), renal disease (kidney), cerebrovascular accident (CVA), non Alzheimer's dementia, Parkinson's disease, and neurocognitive disorder with Lewy bodies (a type of dementia). The MDS documented Resident #1 received antipsychotic 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 observation, resident, family, and staff interviews the facility failed to answer call lights in a timely manner for 4 of 4 residents reviewed (Residents #11, #25, #12 and #7). Findings include: 1. Resident #11's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment indicated that Resident #11 required extensive assistance from 2 persons for transfers and toilet use. Resident #11 required extensive assistance from 1 person with bed mobility and dressing. The MDS included diagnoses of depression and psychotic disorder. During an interview on 10/30/23 at 1:46 PM, Resident #11 reported that she sometimes waits 45 minutes in afternoon and evening for staff to come answer her call light. During an interview on 11/2/23 at 8:21 AM, Resident #11 reported that the morning staff has put her in the bathroom on the toilet and left her there. She added that at times she waits up to 45 minutes for the staff come back, after…

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, facility documentation, and policy review, the facility failed to ensure staff used proper hand sanitizing to prevent or spread infection. The facility also failed to act on resident's personal refrigerators that were out of safe temperature ranges for storing food. The facility reported a census of 55 residents. Findings include: On 10/31/23 at 7:50 AM, observed Staff F, Personal Nutritional Assistant (PNA), assisting two residents to eat their breakfast. Staff F sat down between the two residents and began to alternate feeding the residents. She then got up, grabbed a paper from another table, came back and resumed feeding the residents. Observed Staff F use her hand to put her hair behind her ears and continue to help the residents eat without completing hand hygiene. Staff F got up again and went to a counter and picked up a walkie talkie. She returned to the residents sat down and continued to feed the residents without completing hand hygiene. Witnessed the Director of Nursing (DON) approach Staff F and speak with her. As the DON walked…

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 and staff interviews, the facility failed to provide satisfactory evidence that they identified their own high risk, high volume, and problem-prone quality deficiencies, and made a good faith attempt to correct them. The facility reported a census of 55 residents. Findings included: During an interview on 11/2/23 at 10:00 AM, the Administrator reported information discussed at safety meeting and Quality Assurance (QA) are privileged information and protected by law so he could not give that information. Review of a document provided by the Director of Nursing (DON) on 11/2/23 at 10:45 AM listed 3 incidents for residents that happened in September. The document reflected the type of incident that occurred and the intervention put in place. The document lacked a complete detailed report of investigating, analysis, and prevention of adverse events. During an interview on 11/2/23 at 12:40 PM, the DON reported that the facility did not do root cause analyses for incident reports. She verbalized the facility goes over the incident by talking about what…

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

Based on personnel file reviews, facility policy review, and staff interview, the facility failed to provide dependent adult abuse recertification training within 3 years for 1 of 5 employees reviewed (Staff B). The facility identified a census of 55 residents. Findings include: The personnel file for Staff B, Licensed Practical Nurse (LPN), listed a hired date of 9/12/22. Staff B's Dependent Adult Abuse Mandatory Reporter Training Certificates reflected that they completed the 2 hour dependent adult abuse training on 2/21/20 and a 1 hour dependent adult mandatory reporter recertification training on 5/23/23. The Dependent Adult Abuse Awareness and Training Policy revised 12/30/20 instructed that each employee shall be required to take a 1 hour recertification training within 3 years of the initial 2 hour training and every three years thereafter. On 11/2/23 at 9:05 AM, Staff C, Human Resources, acknowledged that Staff B completed their Dependent Adult Abuse Recertification training late.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to notify the physician of significant weight gains for 1 of 2 residents reviewed (Resident #38). Findings include: Resident #38's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment indicated that Resident #38 weighed 237 pounds (lbs.) and had no significant changes in weight. The MDS included diagnoses of heart failure, atrial fibrillation, end stage renal disease, respiratory failure, diabetes, and obstructive sleep apnea. Resident #38's undated Care Plan documented that she had a risk for dehydration related to her dialysis and fluid restriction. The Interventions listed on the Care Plan directed the staff to weigh her at the same time of day with the wheelchair scale, then notify the physician of a weight gain of 2-3 lbs. in 24 hours or 5 lbs. in 5 days. Resident #38's Weight Summary lacked weights for August on the 1st, 6th, 18th,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, staff file review and policy review the facility failed to report a potential abuse to the surveying agency for 1 of 3 residents (Resident #308). Staff reported to the administration that Staff I, Certified Nurse Aide (CNA), pushed Resident #308 back into a chair in a rough manner. A video recording contained the interaction and the personal file contained a counseling note. The facility did not report the incident to the proper authorities. Findings include: Resident #308's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #308 required extensive assistance from 1 person for dressing, toilet use, and hygiene. In addition, Resident #308 required limited assistance from 1 person for locomotion. The MDS included diagnoses of unspecified dementia with behavioral disturbances, generalized anxiety disorder, and unspecified dementia with agitation. The Care Plan cancelled on 9/6/23, reflected that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, staff file review and policy review the facility failed to thoroughly investigate a potential abuse situation for 1 of 1 resident reviewed (Resident #308). The staff reported to the Administration that Staff I, Certified Nurse Aide (CNA) pushed Resident #308 into a chair in a forceful manner. A video recording contained the interaction and the facility counseled Staff I. Findings include: Resident #308's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #308 required extensive assistance from 1 person for dressing, toilet use, and hygiene. In addition, Resident #308 required limited assistance from 1 person for locomotion. The MDS included diagnoses of unspecified dementia with behavioral disturbances, generalized anxiety disorder, and unspecified dementia with agitation. The Care Plan cancelled on 9/6/23, reflected that Resident #308 had a risk for falls related to his gait and balance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews the facility failed to send a copy of a notice of transfer to a representative of the Office of the State Long Term Care Ombudsman for 3 of 3 residents reviewed (Resident #4, #49, and #38). Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Resident #4's Clinical Census reviewed on 10/31/23 listed a status of hospital paid leave on 8/9/23 and 9/22/23. The August 2023 Ombudsman Notification form lacked documentation of her discharge to the hospital on 8/9/23. The September 2023 Ombudsman Notification form lacked documentation of her discharge to the hospital on 9/22/23. 2. Resident #49's MDS assessment dated [DATE] listed a readmission date of 7/23/23 from an acute hospital. The MDS identified a BIMS score of 14, indicating intact cognition. Resident #49's Clinical Census listed a status of hospital paid leave on 7/17/23 and 7/19/23.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review the facility failed to provide a bed hold notice for 2 or 3 residents reviewed (Residents #4 and #49). Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Resident #4's Clinical Census reviewed on 10/31/23 listed a status of hospital paid leave on 9/22/23. The clinical records lacked documentation that the facility provided a bed hold notification to Resident #4 or Resident #4's Representative when the she discharged to the hospital on 9/22/23. On 10/31/23 at 3:00 PM, the Director of Nursing (DON) reported they did not do a bed hold because Resident #4 went out on 9/22/23 and came back in the early morning at 4:30 AM on 9/23/23. She verbalized she realized she was out overnight so it should have been done. The Reserve Bed Policy, revised September 2013 directed that the facility provide the resident or the resident'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 interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for 2 of 3 reviewed (Residents #4 and #11). Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] reflected that she had a level II PASRR condition of intellectual disability. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. The MDS included diagnoses of anxiety disorder, bipolar disorder, and borderline personality disorder. Resident #4's Notice PASRR Level II Outcome dated 5/7/23 listed the date the short-term approval ends as 11/3/23. Resident #4's clinical records lacked documentation that the facility tried to move toward a successful discharge to a lower level of care prior to the short-term approval ending. During an interview on 11/1/23 at 11:35 AM, the Social Worker reported she resubmitted a new PASRR for short-term stay on Monday (10/30/23). She reported she did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to develop a Care Plan that addressed risk factors and interventions related to type 2 diabetes for 1 out of 20 residents (Resident #25) reviewed for comprehensive Care Plans. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, transfers and toilet use. The MDS included diagnoses of anemia, heart failure (inability of the heart to pump blood), renal disease (kidney), diabetes mellitus, and Alzheimer's disease. The MDS documented Resident #25 received insulin injections 7 out of 7 days in the lookback period. Resident #25's November 2023 Medication Administration Record (MAR) included the following orders: a. Start date 11/4/22: Insulin Aspart (rapid-acting insulin) Solution inject 22 units…

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 update care plans with fall interventions and feeding assistance needs for 2 of 6 residents reviewed (Residents #1 and #5). The facility reported a census of 55 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition. The MDS indicated that Resident #1 required extensive assistance of one person for bed mobility, transfers, ambulation, dressing, and personal hygiene, and extensive assistance of two persons for toilet use. The MDS included diagnoses of non-traumatic brain dysfunction, diabetes, Alzheimer's disease, moderate intellectual disabilities, and Down syndrome. The Care Plan, dated 8/14/23 included a Focus that Resident #1 had a risk for falls related to confusion, gait problems, balance problems, incontinence, vision problems, hearing problems, and unaware of his safety needs. The Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #49's MDS assessment dated [DATE] listed a readmission date of 7/23/23 from an acute hospital. The MDS identified a BIMS score of 14, indicating intact cognition. The assessment reflected that Resident #49 had impaired range of motion (ROM) to one side of the upper extremity. The hospital Transfer/Discharge/Active Orders dated 4/18/23 included an order for continuous use of a splint to his right wrist, hand, remove 3 times a day to complete hygiene cares and check for skin breakdown. Resident #49's October 2023 Treatment Administration Record (TAR) included an order on 5/13/23 for edema glove on in morning (AM) and off at bedtime (HS). On 10/30/23 at 11:54 AM observed Resident #49 in the dining room without an edema glove and/or a splint to his right hand. On 10/30/23 at 4:00 PM witnessed Resident #49 in his room without an edema glove and/or a splint to his right hand. On 10/31/23 at 9:45 AM observed Resident #49 in his room without an edema glove and/or a splint to his right hand. On 10/31/23 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 observations, interviews, and chart review the facility failed to offer the use of a toilet on a timely basis to 1 of 3 residents reviewed (Resident #45). An observation revealed Resident #45 sitting in his chair for over 4 hours before someone offered to take him to the toilet. Findings include: Resident #45's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS lacked behavior symptoms. He used a walker and a wheelchair. He required substantial assistance (more than half of the effort) with toilet use. The assessment described Resident #45 as frequently incontinent of bladder. The MDS included diagnoses of non-traumatic brain dysfunction, dementia and psychotic disorder. The Care Plan with a Target Date of 1/9/24 included the following Focuses: a. Resident #45 had bladder incontinence. b. Resident #45 had a risk for falls related to confusion, gait/balance problems, incontinence and he lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews the facility failed to reassess 1 of 1 resident reviewed (Resident #11) for electric wheelchair safety after an accident. Findings include: 1. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment described her as independent with set up assistance with locomotion on and off the unit. The MDS indicated the she used a wheelchair. The Communication - with Resident note dated 9/15/23 at 3:00 PM identified that Resident #11 reported to the nurse that while she went to the library on the previous day, the left foot pedal got pushed with her foot on it. She explained that the elevator door pushed her foot pedal up far, bending her foot up. She said she noticed some pain while transferring to the bed the previous night but did not say anything due to it being mild. Resident #11 reported to the nurse that she had increased pain of an 8 out of 10 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 observations, interview and record review the facility failed to reposition residents to prevent pressure for 2 of 3 residents (Residents #307 and #45). In addition, the facility failed to provide range of motion exercises as recommended for 1 of 1 residents (Resident #12). Findings include: 1. The Baseline Care Plan (BCP) dated 10/26/23, identified that Resident #307 required assistance from 2 persons with bed mobility, transfers and toilet use. He had a coccyx wound that measured 1.2 centimeters (cm) length x 1 cm width x 0.1 cm depth. The BCP described Resident #307 as very weak and admitted to the facility with hospice services. The Medical Diagnosis Sheet reviewed on 11/1/23 at 10:02 AM listed diagnoses of pneumonia and congestive heart failure. The Care Plan with a Target Date of 1/24/24 included the following Focuses: a. Resident #307 had a terminal prognosis related to heart failure. The Intervention directed the following: 1. Work with nursing staff to provide maximum comfort and wishes with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #46's MDS assessment dated [DATE] identified a BIMS score of 15 indicating cognitively intact. Resident #46 ate with set-up help and supervision. The MDS included diagnoses of heart failure, hypertension, and renal insufficiency. Resident #46 received a mechanically altered diet and a therapeutic diet. The Care Plan with a target date of 12/20/23 included a Focus that indicated Resident #46 had nutritional risks related to diabetes mellitus type 2, congestive heart failure, end stage renal disease, and dialysis. He needed a mechanical and therapeutic diet. The Interventions directed the following: a. Encourage him to follow his order for fluid restriction b. Resident #46 would receive a renal diet, mechanical soft texture, regular fluid consistency, and a 1500 cc fluid restriction. c. Order for a fluid restriction of 1500 cc per day - refer to specific breakdown and guidelines. The Communication - with Physician Note dated 9/18/23 at 4:35 PM reflected that the facility received a fax from the doctor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide enteral (fluids delivered directly into the stomach) water as ordered for 1 of 2 residents reviewed (Resident #42). Resident #42 required tube feedings and experienced increased vomiting. On 10/27/23 the dietician recommended a decrease in the water flow in his 24-hour tube feedings. An order was entered on 10/30/23 to decrease the fluids with feedings from 25 milliliters (ml) an hour to 20 ml. On 10/30/23, 10/31/23 and 11/1/23 an observation revealed the water flow still set on 25 ml. As of 11/1/23 at 7:00 AM the facility still did implement the order change. Findings include: Resident #42's Minimum Data Set (MDS) assessment dated [DATE], identified that he had severely impaired cognitive skills for daily decision making. Resident #42 required total assistance from one staff for bed mobility, transfers, locomotion, toilet use, and personal hygiene. The MDS included diagnoses of cerebral palsy (a group of disorders that affects…

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 do a dialysis assessment or a complete before and/or after dialysis assessment for 2 of 2 residents reviewed (Resident #46 and #38). Findings include: 1. Resident #46's MDS assessment dated [DATE] identified a BIMS score of 15 indicating cognitively intact. Resident #46 ate with set-up help and supervision. The MDS included diagnoses of heart failure, hypertension, and renal insufficiency. Resident #46 received a mechanically altered diet and a therapeutic diet. The MDS listed that Resident #46 received dialysis while a resident at the facility during the lookback period. The Care Plan with a target date of 12/20/23 included the following Focuses: a. Resident #46 received dialysis 3 times a week. The Interventions directed the following: - Resident #46 received dialysis on Monday, Wednesday, and Friday. - Nursing staff to check his port (fistula or dialysis access) on his left upper arm and document any concerns. - Staff to check…

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 provide adequate monitoring of prophylactic (preventative) antibiotic use for 1 resident reviewed, (Resident #38). The facility notified Resident #38's primary provider. When the primary provider replied that a specialist provided the order, the facility failed to contact the prescribing provider to review the prophylatic order. Findings include: Resident #38's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment indicated that Resident #38 weighed 237 pounds (lbs.) and had no significant changes in weight. The MDS included diagnoses of heart failure, atrial fibrillation, end stage renal disease, respiratory failure, diabetes, and obstructive sleep apnea. Resident #38 received a mechanically altered diet and a therapeutic diet. The assessment indicated that she used an antibiotic for 7 out of 7 days in the lookback period. Resident #38…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to discontinue an as needed (PRN) antipsychotic medication (haloperidol or Haldol) or seen by the provider within 14 days to determine the necessity of the medication for 1 of 5 residents reviewed (Resident #45). The Pharmacist recommended that the physician see Resident #45 still needed the medication, the benefit of the medication, and/or if the medication helped him. The facility failed to implement the recommendation for two months after the pharmacy review. Findings include Resident #45's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS lacked behavior symptoms. He used a walker and a wheelchair. He required substantial assistance (more than half of the effort) with toilet use. The assessment described Resident #45 as frequently incontinent of bladder. The MDS included diagnoses of non-traumatic brain dysfunction, dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to wear gloves to remove a used dirty dressing while completing wound care for 1 of 1 resident reviewed (Resident #26). Findings include: Resident #26's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of atrial fibrillation, heart failure, hypertension, renal failure, asthma, chronic respiratory failure, and a stage 4 pressure ulcer of the left ankle. The Physician Orders' reviewed on 11/2/23 at 11:30 AM included the following orders: a. Dated 10/16/23: Clean right lateral ankle with soap and water, then apply Providone iodine swabs to wound bed, then apply triamcinolone 0.1% cream around the wound bed, and cover with a Mepilex dressing. b. Dated 10/16/23: Clean left ankle wound with soap and water, then apply Providone iodine swabs to wound bed, then apply triamcinolone 0.1% cream around the wound bed, and cover with a Mepilex dressing. 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.