Parkview Manor

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to investigate allegations of abuse and failed to ensure separation between the alleged perpetrator of abuse and residents for 2 of 2 residents reviewed for abuse(Residents #2 and #7). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 2/4/25, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, multiple sclerosis(a disease which causes impairment in the nerves), and diabetes. The MDS stated the resident required partial/moderate assistance with toileting hygiene and listed her Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition. The facility Abuse Prevention policy, dated 10/21/22, stated the facility was committed to protecting the residents from abuse by anyone including facility staff. The policy stated the facility would investigate allegations of abuse and suspend employees accused of abuse during the investigation. Review of Care Plan,…

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

Based on clinical record review, policy review, and staff interview, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 1 discharges reviewed (Resident #8). The facility reported a census of 49 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A 2/4/25 Health Status Note stated the resident had increasing behaviors and the facility sent him to the hospital for evaluation. The facility lacked documentation of resident representative and ombudsman notification of discharge. On 3/27/25 at 10:21 a.m., via email, the Administrator stated the facility did not notify the ombudsman of the…

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

Based on clinical record review, policy review, and staff interview, the facility failed to provide the resident and/or the resident's representative(s) a notice of bed-hold policy for 1 of 1 discharges reviewed (Resident #8). The facility reported a census of 49 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Resident Bed Hold, dated 11/15/22, stated the facility would provide written information to the resident and/or the resident representative regarding the bed hold policy prior to transferring the resident to the hospital. The facility would provide written information about these policies prior to and upon transfer for such absences. A 2/4/25 Health Status note stated the facility planned to transfer the resident to the hospital. The note lacked documentation of family notification of the transfer or bed hold…

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

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the completion of proper notices and documentation after they did not allow a resident to return to the facility after a hospitalization for 1 of 1 discharged residents reviewed(Resident #8). The facility reported a census of 49 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The MDS stated the resident had no behaviors during the review period. The facility policy Notification of Transfer and Discharge, dated 3/17/25, stated the facility would provide the resident and resident representative notice of an impending transfer or discharge which would include the reason for discharge and information regarding appeal rights. A 10/24/24 Nurses Notes stated the resident admitted to the facility and was pleasant and cooperative. A 12/14/24…

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.

Based on clinical record review, policy review, and staff interview, the facility failed to provide emergency services in a timely manner (Resident #8). The facility reported a census of 49 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The MDS stated the resident had no behaviors during the review period. The facility policy Notification of a Change in Condition, revised 4/26/23, stated the facility would notify the provider of a resident's change in condition including unusual behavior. A 2/2/25 Nurses Note stated the resident had increased behaviors. A 2/4/25 8:37 a.m. Health Status note stated the resident was behaviorally different from baseline after his electroconvulsive therapy (ECT) treatment yesterday. Throughout the evening and overnight, the resident's behaviors became increasingly erratic and included, urinating 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, provider and staff interviews, the facility failed to develop interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition from the facility to a post-discharge setting. (Resident #3) The facility reported census was 47. Findings include: The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #3 included: diabetes mellitus, and neurogenic bladder. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS assessed Resident #3 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was occasionally incontinent of bladder. The MDS documented Resident #3 had taken a hypoglycemic (medication used to lower blood sugar, includes insulin). A review of the clinical record revealed a Nurses Note, dated 8/30/24 at 9:55 a.m., documenting Resident #3 given discharge information. Reviewed signs and symptoms of high and low…

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 and staff interviews, call light logs, facility policy and resident council minutes the facility staff failed to respond to call lights within a reasonable amount of time. Residents reported having to wait from 30 minutes to over an hour for the call light to be answered numerous times (Resident #10, #22, #34, & #50). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #22 revealed a diagnosis of obesity and a chronic wound to the left foot therefore required the assistance of 1 for dressing and personal hygiene. Resident # 22 had a Brief Interview for Mental Status (BIM) score of 15 suggesting an intact cognition. During an interview on 8/05/24 at 9:19 AM, Resident #22 stated the staff are often slow at answering her call light, 30 mins to 2 hours. Resident #22 stated if it's longer than 45 minutes, she will call the front desk, if no answer, then she will call the social worker. Resident #22 stated she can…

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

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to carry out a treatment as ordered for 1 of 3 residents reviewed(Resident #34). The facility reported a census of 53 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon…

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, clinical record review, and facility policy review, the facility failed to elevate the head of bed during administration of enteral feeding and failed to label supplemental formula bag with the date and time that enteral feeding had started for 1 of 2 residents (Resident #33) reviewed for enteral/tube feeding. The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Resident #33 required partial to moderate staff assistance to turn and reposition in bed and had been dependent upon staff to transfer. Diagnoses included alcohol induced acute pancreatitis without necrosis or infection, malnutrition, generalized peritonitis, sacroiliitis, autoimmune thyroiditis, and gastrostomy status. Resident #33 required feeding tube prior to and while a resident at facility, she received 25% or less proportion of total calories…

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 practice appropriate infection control measures with the laundry, during the passing of ice water, provide environmental cleaning and disinfecting of areas between laundry and dietary and were low on Personal Protective Equipment (PPE) gloves, not readily accessible in all resident areas. The facility reported a census of 53 residents. During an observation on 8/05/24 at 11:40 AM, Staff L, Hospitality Aide passed water, filled the ice cup for resident's residing in the 200 hall and dropped the scoop back into the ice and closed the lid at each resident room. During an observation on 8/06/24 at 11:02 AM, Staff E, Laundry Aide delivered towels and washcloths to the large laundry carts in the halls. The wire basket containing the clean laundry brought up from the basement laundry room was not covered. During an observation on 8/7/24 at 7:56 AM, in the hallway by the elevator leading to laundry services and the backdoor of the kitchen, a bag of trash with brown liquid substance in a wire basket dripped a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, the facility failed to administer medications as ordered for 1 of 5 residents reviewed (Resident #1). The facility's failure resulted in Resident #1's increased agitation and escalation of physical behaviors that resulted in aggressive physical contact between Resident #1 and another resident (Resident #2). In addition, a staff member, Staff A, Certified Nurse Aide (CNA), got injured from an encounter with Resident #1. The facility reported a census of 55 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed his admission date as 5/30/24 from an inpatient psychiatric hospital. Resident #1 could make himself understood, and usually understood others. The MDS reflected Resident #1 had a Level II Preadmission Screening and Resident Review (PASRR) initated for severe mental illness. The MDS indicated he had delusions, physical, and verbal behaviors directed towards others that occurred from 1 to 3 days 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 observation, clinical record review and staff interview, the facility failed to ensure residents are treated with dignity while being provided care for 2 of 4 residents reviewed. (Residents #14, #21) The facility reported census was 46. Findings include: 1. According to the Quarterly Minimum Data set (MDS) with an assessment reference date of 4/3/24, Resident #14 had a severely impaired cognitive status. Resident #14 required total dependence with mobility, transfers, dressing, toilet use and personal hygiene needs. The MDS documented Resident#14's diagnoses included Cerebral palsy, obstructive uropathy. During an observation on 5/2/24 at 1:50 p.m. Resident #14 was propelled back to his room and transferred into bed with a mechanical lift and assistance of two staff members (Staff D, Certified Nurses Aide (CNA)/Staff P, CNA). Both staff donned proper personal protective equipment (PPE) in accordance with Enhanced Barrier Precaution (EBP) protocols. Staff P proceeded to provide peri care and noted 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 observations, clinical record review and staff interviews, the facility failed to ensure the facility remains free of persistent odors. (Resident #21) The facility reported census was 46. Findings include: According to the Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/5/24, Resident #21 had a minimally impaired cognitive status. Resident #21 required limited assistance with mobility and transfers. Moderate to maximal assistance with dressing, toilet use and personal hygiene needs. Resident #21 was frequently incontinent of bladder and always incontinent of bowel. During an observation on 5/7/24 at 8:00 a.m. a strong odor of urine detected on 100 hall, permeating primarily from room [ROOM NUMBER] (Resident #21's room). During an observation on 5/9/24 at 12:15 p.m. Resident #21 sat in his wheelchair with the television on, but appeared asleep. A strong urine odor was noted upon entering Resident #21's room. During an observation on 5/13/24 at 12:00 p.m. Resident #21's room 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.

Based on clinical record review, the facility failed to complete treatment of wounds in accordance with physician orders for 2 of 2 resident reviewed. (Resident #12, #15) The facility reported census was 46. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 4/8/24, Resident #15 had a Brief Mental Status (BIMS) score of 8 which indicated a moderately impaired cognitive status. Resident #15 was independent with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #15's diagnosis included Non-Alzheimer's dementia, septicemia, chronic obstructive pulmonary disease and respiratory failure. According to Resident #15's Physician's orders dated 4/24/24 and April and May 2023 Treatment Administration Record (TAR), Resident #15 was to have her face washed four times per day with bacitracin and Vaseline on gauze applied over her nose and ears. The April TAR indicated this treatment was not completed two times on 4/25/24, and the May TAR indicated this treatment was not completed three times on 5/1/24. According to Resident #15'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.

Based on observation, clinical record review, bathing records and staff interview, the facility failed to ensure residents are provided adequate personal hygiene services to include at least two bathing opportunities per week for 3 of 4 residents reviewed and failed to provide catheter care in accordance with professional standards of practice. (Residents #12, #14, #18) The facility reported census was 46. Findings include: 1. According to Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/6/24, Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated an intact cognitive status. The MDS documented that the resident required dependent to maximal assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. The MDS coded Resident #12 as always incontinent of bowel and bladder. The MDS documented the resident with diagnoses which included coronary artery disease, peripheral vascular disease, renal insufficiency, diabetes mellitus, cerebrovascular accident (stroke), hemiplegia and chronic obstructive pulmonary…

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

Based on clinical record review, staff written statements, policy review, and staff interviews, the facility failed to immediately protect a resident after an allegation of abuse(Resident #2) for 1 of 2 resident's reviewed for an allegation of staff to resident abuse, failed to protect residents from resident-to-resident abuse for 7 of 7 residents reviewed for resident-to-resident abuse(Residents #2, #3, #4, #5, #8, #11, and #15), and failed to investigate an injury of unknown origin(a buttock bruise) for 1 of 9 residents reviewed for abuse(Resident #10). The facility reported a census of 50 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 6/8/23, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, traumatic brain injury, and communication deficit. The MDS stated the resident had physical behavioral symptoms directed towards others(e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 1-3 days in the 7 day review period and listed the resident's Brief Interview for Mental Status(BIMS) score…

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 follow physician's orders for 4 of 7 residents reviewed for medications(Residents #1, #6, #9, #14). The facility reported a census of 50 residents. Findings Include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 10/25/23, listed diagnoses for Resident #1 which included schizophrenia, major depressive disorder, and dementia. The MDS stated the resident was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and chair to bed transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. The facility policy Medication Administration-General Guidelines, dated 12/17, stated medications were administered as prescribed in accordance with good nursing principles and practices. The facility policy Physician Orders, dated 9/28/22, stated the policy provided guidance to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to maintain sufficient staffing in order to carryout treatment orders for 2 of 3 residents reviewed for pressure ulcers(Resident #1 and #9) and medication orders for 4 of 7 residents reviewed for medications(Residents #1, #6, #9, #14). The facility reported a census of 50 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous…

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 Quality Assurance (QA) meeting documentation, policy review, and staff interview, the facility failed to carry out quality assurance activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 50 residents. Findings Include: The facility policy Quality Assurance and Process Improvement (QAPI), reviewed 8/20/20, stated the QA Committee would meet monthly and discuss quality measures and concerns and implement action items for improvement. Review of QA meeting documentation from May 2023 until the start of the current survey on 11/28/23 revealed the facility held a QA meeting on 6/29/23. The facility lacked documentation of further QA activities during this time frame. On 1/4/23 at 9:15 a.m. via phone, the Administrator stated the only QA documentation she could locate between May of 2023 and current was in June 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.

Based on clinical record review, written staff statements, policy review, and staff interview, the facility failed to treat residents with dignity by posting a picture of a resident on social media(Resident #15) and speaking to/handling a resident in a rough manner(Resident#2) for 2 of 5 residents reviewed for dignity. The facility reported a census of 50 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 6/8/23, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, traumatic brain injury, and communication deficit. The MDS documented the resident had physical behavioral symptoms directed towards others(e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 1-3 days in the 7 day review period and listed the resident's Brief Interview for Mental Status(BIMS) score as 4 out of 15, indicating severely impaired cognition. A 6/15/22 Care Plan entry stated the resident had the potential to be verbally and physically aggressive. A 4/13/23 Care Plan entry directed staff to analyze the triggers of the…

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

Based on clinical record review, policy review, and staff interviews, the facility failed to notify a family member of a finger injury for 1 of 3 residents reviewed for a change in condition(Resident #10). The facility reported a census of 50 residents. Findings Include: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 8/6/23, listed diagnoses for Resident #10 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident was independent with bed mobility, transfers, walking, and eating, required limited assistance of 1 staff for dressing, toilet use, and personal hygiene, and extensive assistance of 1 staff for bathing. The MDS documented the resident's cognition was severely impaired. The facility policy Notification of a Change in a Resident's Condition, dated 4/28/21, directed staff to notify a resident's representative after any accident or incident. An 8/11/23 1:19 p.m. Nurses Note stated the resident had bruising and swelling to her left ring finger at 6:30 a.m. and had pain which increased her anxiety. An 8/14/23…

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 clinical record review, policy review, and staff interview, the facility failed to report an injury of unknown origin to the State Agency for 1 of 9 resident's reviewed for abuse(Resident #10). The facility reported a census of 50 residents. Findings Include: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 8/6/23, listed diagnoses for Resident #10 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident was independent with bed mobility, transfers, walking, and eating, required limited assistance of 1 staff for dressing, toilet use, and personal hygiene, and extensive assistance of 1 staff for bathing. The MDS stated the resident's cognition was severely impaired. The facility policy Abuse Prevention revised 10/21/22, stated the facility would report all injuries of unknown source immediately but not later than 2 hours after the allegation was made. An 8/18/23 12:29 p.m. Nurses Note stated the resident's daughter stated while the resident was out, she noticed a bruise to the left buttock and requested 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, clinical record review, policy review, and staff interview, the facility failed to provide timely incontinent cares for 1 of 3 residents reviewed for personal cares(Resident #17) and failed to complete oral cares for 1 of 3 (Resident #13)residents reviewed for oral cares. The facility reported a census of 50 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 11/4/23, listed diagnoses for Resident #17 which included non-Alzheimer's dementia, hemiplegia(one-sided paralysis), and malnutrition. The MDS stated the resident was dependent on staff for toileting hygiene and listed the resident's Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition. A Care Plan entry, dated 10/4/21, stated the resident was incontinent(unable to control their bowels and/or bladder) and directed staff to check and change his incontinent brief. The facility policy Incontinent Care dated 7/21/23, stated the facility would provide…

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, observations and staff interviews, the facility failed to provide proper care for a gastric tube and failed to provide nutritional feeding as per physician orders for 2 of 2 residents reviewed for tube feeding (Resident #13 & #14). The facility reported a census of 50 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident # 14 revealed a diagnosis of cerebral palsy, aphasia (inability to communicate), dysphagia (swallowing disorder) and profound intellectual disabilities, identified a tube feeding and listed the Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating severely impaired cognition. The MDS documented that the portion total calories the resident received through tube feeding was 51% or more, and the average fluid intake per day by feeding tube was 501 milliliters per day or more. The Care Plan dated 11/16/23 for Resident #14 directed staff to flush the feeding tube with 30 milliliters (ml) of water before and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to prevent significant medication errors for 2 of 7 residents reviewed for medications(Resident #1 and #21). The facility reported a census of 50 residents. Findings includes: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 10/25/23, listed diagnoses for Resident #1 which included schizophrenia, major depressive disorder, and dementia. The MDS stated the resident was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and chair to bed transfers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 0 out of 15, which indicated severely impaired cognition. The facility policy Transdermal Drug Delivery System (Patch) Application, dated 12/17, directed staff to remove old patches prior to the application of a new patch. The facility policy Medication Administration-General Guidelines dated 12/17, stated medication were…

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 reviews, interviews, and facility policy review, it was determined that the facility failed to ensure pneumococcal vaccine education was provided and the vaccine was offered to 4 (Residents #24, #40, #41, and #43) of 5 residents reviewed for immunizations. Findings included: A review of a facility policy titled, Pneumococcal Vaccine Policy, dated March 2017, revealed, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty-five (35) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within fifteen (15) working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. A review of an admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review the facility failed to ensure a resident was referred for a Level I Preadmission Screening and Resident Review (PASRR) when the resident experienced a change and had a newly diagnosed mental illnesses for 1 (Resident #25) of 2 residents reviewed for the PASRR assessment. Findings included: A review of a document provided by the facility titled, PASRR [Preadmission Screening and Resident Review] and Level of Care Screening Procedures for Long Term Care Services, revised 08/19/2020, indicated, The purpose of the Level I screen is to identify individuals intended for evaluation through the PASRR Level II process - those individuals with known or suspected MI [Mental Illness] and ID/RC [Intellectual Disability/Related Condition]. The document further indicated the Level I screen must be submitted For residents of Medicaid certified NFs [Nursing Facilities] experiencing changes in status that suggests the need for a first-time or updated PASRR Level II…

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, interviews, record reviews, and facility policy review, it was determined that the facility failed to ensure medications were properly labeled for 1 (Resident #32) of 3 resident medications observed on the South Hall medication cart. Findings included: Review of a facility policy titled, Storage of Medications, dated June 2015, revealed, All medications dispensed by the pharmacy are stored in the container with the pharmacy label. The policy further indicated, When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). A review of an admission Record indicated the facility admitted Resident #32 on 11/04/2022 with diagnoses that included chronic obstructive pulmonary disease. A review of Resident #32's Order Summary Report, revealed an order, dated 05/09/2023, for albuterol sulfate inhaler,…

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.

THE FOLLOWING DEFICIENCIES RELATE TO THE IOWA ADMINISTRATIVE CODE (IAC) CHAPTER 58. 58.12(135C) Admission, transfer, and discharge. 58.12(1) General admission policies. l. For all residents residing in a health care facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249A on July 1, 2003, and all others subsequently admitted , the facility shall collect and report information regarding the resident's eligibility or potential eligibility for benefits through the Federal Department of Veterans Affairs as requested by the Iowa commission on Veterans Affairs. The facility shall collect and report the information on forms and by the procedures prescribed by the Iowa commissions on veteran's affairs. Where appropriate, the facility may also report such information to the Iowa department of human services. In the event that a resident is unable to assist the facility in obtaining the information, the facility shall seek the requested information from the resident's family members or responsible party. For all new admissions, the facility shall…

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, it was determined that the facility failed to document the record of death for 1 (Resident #45) of 2 sampled residents that expired in the facility. The facility further failed to properly transcribe orders for 1 (Resident #6) of 3 residents observed for medication administration. Specifically, the facility failed to transcribe an order to discontinue Resident #6's Lotensin (a medication used to treat high blood pressure) when a new order was received on [DATE]. Findings included: 1. Review of Resident #45's admission Record, revealed the facility admitted the resident on [DATE] with diagnoses that included hypertension and nonrheumatic aortic (valve) stenosis. The admission Record also indicated Resident #45 was discharged to a funeral home on [DATE]. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively 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.