Pine Acres Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility policy review, and record review, the facility failed to ensure staff followed a gastrostomy tube (G-tube) feeding order for 1 of 4 residents reviewed (Resident #85) reviewed for nutrition. The facility reported a census of 81 residents. Findings include:Review of Resident #85's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS recorded active diagnoses of a stroke, aphasia (difficulty speaking), hemiplegia (one-sided paralysis), dysphagia (difficulty swallowing), and a neurogenic bladder (loss of bladder control) with the need for a catheter. The MDS documented an impairment to one side of the upper extremities and an impairment to both sides of the lower extremities. The MDS coded Resident #85 as dependent on the assistance of two persons with the use of a mechanical lift and a wheelchair for ambulation. The MDS failed to document Resident #85's gastrostomy tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review, the facility failed to administer insulin medication as ordered for Resident #79 and failed to discontinue an anticoagulant (blood thinning) medication for Resident #52, for 2 of 2 residents reviewed for significant medication errors. The facility reported a census of 81 residents. 1. Resident #79's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented active diagnoses of hypertension (high blood pressure), diabetes mellitus (chronic high blood sugar), anxiety (excessive persistent worry), and depression (persistent sad mood). Review of Resident #79's physician orders dated 4/16/26 revealed orders for Insulin Lispro injection 100/milliliters, with instructions to inject as directed three times daily after meals and within 30 minutes of meal completion. The ordered dosage depended on meal consumption: 3 units if 25% of the meal 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 observations, staff interviews, and policy review, the facility failed to properly secure medications from unauthorized access by failing to lock 2 of 2 medication carts observed. The facility reported a census of 81 residents. Findings include: On 01/06/26 at 4:56 AM, a medication cart was observed unlocked in a resident hall in front of the nurse's documentation room. The cart contained an antidepressant (duloxetine) and a muscle relaxant (Baclofen). Staff I, Licensed Vocational Nurse (LVN) was observed sitting in the documentation room while the cart drawer was opened for one (1) full minute before she approached the cart. She stated the carts should not be left unlocked but added she was about to access the cart. There were no residents in the hall.On 1/07/26 at 3:05 am, a medication cart and supply cart were discovered unlocked in a resident hall in front of the nurse's documentation room. There were no staff members or residents visible in the unit hallway. The cart contained antidepressants (duloxetine and trazadone), a blood thinner (Eliquis), and a muscle relaxant…

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 interview, and facility policy review the facility failed to prepare and serve food that was palatable for one of four hallways observed. The facility reported a census of 81 residents. Findings include: Observation of the lunch meal service on 1/7/26 revealed the following:a. On 1/7/26 at 11:21 AM, Staff E, dietary cook, removed a large pan containing ham and cheese sandwiches from the oven. Staff D, dietary cook, checked the temperature of the entree and reported they planned to serve the sandwiches during the lunch meal service. Staff D reported the ham and cheese sandwich temperature at 130 degrees Fahrenheit. Staff E stated the cheese was melted (on the sandwiches) and that was what the residents liked. At that time the buns appeared soft. Staff E then placed another large pan of buns with ham and cheese (inside the bun) with a piece of foil over the top of the sandwiches into the oven. b. On 1/7/26 at 11:29 AM, Staff D and Staff E wheeled the warming table with the pan of hot ham and cheese sandwiches to the dining room serving area.…

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

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access by leaving 11 residents' information accessible when staff walked away from the Electronic Health Record (EHR) laptop. The facility reported a census of 81 residents. Findings include: On 1/06/26 at 5:05 AM, a laptop was observed in a resident hall with 11 residents' (301, 304, 305, 306 A, 307, & 308) Electronic Health Record (EHR) information visible.At 5:09 AM, Staff H, Registered Nurse (RN) stated laptops are not to be left open when staff are not present and also stated he didn't know it was open.On 1/08/26 at 2:26 PM, the Director of Nursing (DON) stated the laptop screen should be locked when staff walk away.A policy titled HIPAA Security Measures revised 02/2025 indicated physical safeguards will be implemented that limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident interviews, staff interviews and policy review the facility staff failed to provide care for a resident in an environment that maintained or enhanced dignity for one of twelve residents observed and required assistance for eating (Residents #30). The facility staff also failed to respond in a timely manner to call light and assist a resident off the toilet, and failed to administer pain medication for one of twenty-five residents sampled (Resident #7), and failed to knock and wait for a response before entered a resident's room (Resident #72 & #74) . The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #7 revealed the diagnoses of osteoarthritis, chronic pain and identified a fall that resulted in a fracture. Resident #7 required the assistance of 1 for toileting and transfers. Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 for an intact cognition. The Care Plan for Resident #7…

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

Based on record review, resident interview, staff interviews, and policy review, the facility failed to include interventions for a resident who sustained a fall with an injury (#71) and antianxiety medication and target behaviors for 1 of 5 residents (#41) in the residents' Care Plans. The facility reported a census of 81 residents. Findings include:1) On 1/05/26 at 11:26 AM, Resident #71 stated he had a previous fall from his bed the previous month and was hospitalized . He stated the facility staff directed him to place his bed in the lowest position and to call staff for assistance to prevent any future fall. His bed was not in the lowest position during the interview and there were anti-skid strips on the floor beside his bed.The Minimum Data Set (MDS) assessment for Resident #71 dated 12/11/25 revealed a Brief Interview for Mental Status (BIMS) score was not established. It included diagnoses of a stroke, unsteadiness on feet, and muscle weakness. It indicated the resident was independent with oral, toileting, and personal hygiene and upper body dressing, required supervision…

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 follow the physician's orders for 1 of 3 residents reviewed for change in condition (Resident #83). The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 admitted to the facility on [DATE] from the hospital. The resident had diagnoses of anxiety disorder, depression and toxic encephalopathy. The MDS revealed the resident had a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. The MDS indicated the resident had no behaviors but had little interest in doing things and felt down/depressed 2 to 6 days during the 14 day look-back period. The MDS indicated the resident took an antipsychotic, antianxiety, and an antidepressant medication.The MDS assessment dated [DATE] revealed the resident had an unplanned discharge to the hospital on [DATE]. The Care Plan initiated 12/17/25 revealed the resident had a…

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

Based on observation, clinical record review, staff interview, and policy review, the facility failed to protect a resident's (#54) heels during a mechanical lift transfer and failed to provide supervision for an at-risk resident who went to the courtyard and smoked. The facility reported a census of 81 residents.Findings include:1) The Minimum Data Set (MDS) for Resident #54 dated 12/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of single nerve damage in both legs that causes muscle weakness and a stroke. It indicated he required setup assistance for eating and oral hygiene, moderate assistance with personal and toileting hygiene, and was dependent with all other Activities of Daily Living (ADLs). He also required moderate to maximal assistance with all forms of mobility.The Electronic Health Record (EHR) included a form titled Braden Scale For Predicting Pressure Sore Risk dated 8/19/24 that revealed Resident #54 was a moderate risk for developing a pressure sore.The 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 observations, resident and staff interviews, facility document review and clinical record review, the facility staff did not consistently answer call lights within a reasonable amount of time. Family members and residents reported having to wait thirty to forty-five minutes for the call light to be answered numerous times during the evening and night time. Residents reported during evening cares and shift change the wait is longer. The facility reported a census of 81 residents. Findings include:During an interview on 1/05/26 at 4:10 pm, Resident #7, that had a Brief Interview for Mental Status (BIMS 15) that suggested an intact cognition, stated on 1/4/25 at 6:15 pm, she was assisted by Staff S, Certified Nursing Assistant (CNA) to the toilet and then the aide left the room. Resident #7 stated she had activated the call light within 5 minutes and no staff responded to the call light to assist her back to her bed until 7 pm. During an interview on 1/5/26 at 4:15 pm, Resident #30, that had a BIMS of 15, stated on 1/4/26 at 9 pm she turned her call light on as she needed…

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, hospital record review, resident and staff interviews, and policy review, the facility failed to administer accurate medications to 1 of 13 residents (#38) resulting in a fall and hospitalization due to low pulse and blood pressure. The facility reported a census of 81 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #38 dated 11/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of chronic kidney disease, peripheral vascular disease, high blood pressure, and diabetes mellitus. It indicated she required setup with eating and oral hygiene, required moderate assistance with upper body dressing, maximal assistance with toileting hygiene, bathing, and lower body dressing, and was dependent for personal hygiene. It also indicated she required supervision with ambulating and maximal assistance with all other mobility.On 1/05/26 at 11:54 AM, Resident #38 stated she was given the wrong medications when she was first admitted to the…

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

Based on observation, staff interview, record review, and policy review, the facility failed to implement infection control practices to prevent urinary tract infections (UTI) by lifting an indwelling catheter drainage bag above the resident's bladder during perineal care for 1 of 1 resident (#16). The facility reported a census of 81.Findings include:The Minimum Data Set (MDS) for Residents #16 dated 11/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderately impaired cognition. It included diagnoses of quadriplegia, a stroke, a multidrug-resistant organism infection, abnormal bladder function, and obstructive uropathy (urine unable to drain normally). It indicated the resident required setup assistance with eating, maximal assistance with oral hygiene and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility.The Care Plan revised 4/11/23 indicated the resident was at high risk for developing a UTI (urinary tract infection) due to suprapubic catheter (urinary catheter surgically placed directly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to provide the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #12). The facility reported a census of 81 residents.Findings include: The Minimum Data Set (MDS) assessment, dated 10/2/25 identified an admission date of 9/25/25, the resident was over age [AGE], and had diagnoses that included cancer, sepsis and respiratory failure. The MDS indicated the resident's pneumococcal immunization not up-to-date. The MDS indicated the pneumococcal vaccine not received due to the vaccine not offered.Review of the Iowa Registry Immunization System (IRIS) document scanned into the electronic health record (EHR) revealed Resident #12 had not received a pneumococcal vaccine. The pneumococcal vaccine was recommended and listed as past due. A Pneumococcal Vaccine Consent Form for Resident #12 signed by the resident's representative on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility policy review and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to administer the COVID-19 vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #20). The facility reported a census of 81 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #20 dated 12/22/25 identified an admission date of 4/28/25. The MDS revealed the resident had diagnoses of sepsis and non-Alzheimer's dementia.A COVID-19 Vaccine Consent Form dated 4/28/25 revealed Resident #20 gave consent to receive the COVID vaccine.The electronic health record (EHR) under the Clinical Immunizations tab revealed a COVID-19 booster last administered on 8/26/22.On 1/7/25 at 10:36 AM, review of the clinical record for Resident #20's immunization status revealed a lack of documentation on whether Resident #20 had ever received the requested COVID vaccine. In an interview on 1/7/26 at 2:15 PM, Staff F, Assistant Director 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, facility policy review, and staff interviews the facility failed to follow physician orders to remove a fentanyl patch prior to applying a new patch for 1 of 1 residents (Resident #2) reviewed. The facility reported a census of residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 had diagnoses of cancer, polyneuropathy due to other toxic agents, chronic obstructive pulmonary disease (COPD) and unspecified abdominal pain.The Care Plan initiated on 12/9/24 indicated that Resident #3 used Fentanyl related to pain and directed staff to administer the medication as ordered by the physician.The Physician's Order Summary Report dated 9/5/25 included an order for Fentanyl 25 mcg (micrograms) patch apply one patch topically to skin every 3 days and to remove old patch prior to the applying the new patch and to rotate sites.The Electronic Health Record (EHR) Progress Notes revealed that on 9/6/25 Resident #3 appeared to be confused and unable 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 observations, resident and staff interviews and facility policy review, the facility failed to maintain a safe, clean and comfortable environment, free of possible hazards. The facility reported a census of 79 residents. Findings include:On 08/07/23 at 11:00 AM observation of room [ROOM NUMBER] noted carpet flooring throughout an entire room. The dark beige carpet was excessively stained with dark and pink color spills. The bathroom had a walk-in shower that was not used for bathing. The shower had multiple clear plastic trash bags filled with empty pop cans. The personal hygiene items were stored on the floor (disposable incontinence products). 1. Dining room observation on 8/25/25 at 10:25 am revealed the following:a. Peeling paint in several areas on the ceiling. 2 areas measuring about 1ftx1ft each had eroded from a water leak to the point the drywall was visible and the plaster had fallen off, with the peeled and dried paint hanging down from the ceiling about 5-10 inches in the air. 1 of these…

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

Based on record review, resident interviews, observations, staff interviews, and policy review the facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner to 5 of 5 residents reviewed (Resident #8, #12, #17 , and #5). The facility reported a census of 79 residents. Findings include:1.The Minimum Data Set (MDS) assessment for Resident #16, dated 7/20/25, included diagnoses of morbid obesity and heart failure. The MDS identified the resident was dependent on staff for all cares except eating. The MDS indicated the resident had a Brief Interview for Mental Status score of 13, indicating mild cognitive impairment. Interview on 8/28/25 at 4:00 PM, Resident #16 stated the staff don’t answer the call lights timely, that it takes way over 15 minutes, and the afternoon shift is the worst and the facility is always understaffed. The resident stated the other day it was over 2 hours before they answered his call light as he had timed it on his phone. 2.The MDS assessment for Resident #17, dated 7/22/25, included diagnoses of morbid…

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, observations, staff interviews and policy review the facility failed to maintain infection control practices for 8 of 8 residents reviewed. The facility failed to ensure use of EBP when required, failed to maintain hand hygiene with dining and failed to maintain infection control practices during catheter care. The facility reported a census of 79 residents. Findings include: 1. Observation on 8/19/25 at 12:20 PM Staff B, Certified Nursing Assistant (CNA) was sitting at a rounded table assisting 4 residents to dine. Staff B touched 1 resident’s leg with her gloved hands, then with her gloved hand picked up a 2nd resident’s bread stick and placed the bread stick in the resident’s mouth, then proceeded to touch 2 other residents’ silverware and napkins, Staff B continued to assist all 4 residents throughout the lunch meal with the same pair of gloves on and no hand hygiene performed. 2. The Minimum Data Set (MDS) assessment for Resident #9, dated 6/17/25, included diagnoses of…

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

Based on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (#11) of three residents reviewed. The facility reported a census of 79 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #11, dated 5/22/25, included diagnoses of stroke, Non-Alzheimer's Dementia, and hemiplegia (paralysis of one side of the body). The MDS identified the resident was dependent on staff for toilet hygiene and was always incontinent of urine and frequently incontinent of bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Observation on 8/20/25 at 8 AM, Staff A, Certified Nursing Assistant (CNA) and Staff C, CNA entered Resident 11's room and washed hands and donned gloves. With the resident lying in bed, Staff A removed the resident's visibly wet brief, cleansed above the penis, the penis, and the scrotum, without cleansing the inner thighs. The resident was turned to his side and Staff A cleansed between the resident's buttocks 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.

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification survey. The facility reported a census of 75 residents. Findings include: Review of facility's CMS 2567 from recertification and complaint surveys on 12/19/24, 10/31/24, 10/10/24, and 6/19/24 revealed the facility received non-harm level citations for Develop/Implement Comprehensive Care Plan, Care Plan Timing and Revision, Free of Accident Hazards/Supervision/Devices, Label/Storage Drugs & Biologicals, Sufficient/Competent and Infection Prevention & Control. The facility's plan of correction for an annual recertification survey dated 12/19/24, revealed correction date of 1/23/25 for Develop/Implement Comprehensive Care Plans, Care Plan Timing and Revision, Free of Accident/Hazards/Supervision/Devices, and Infection Prevention and Control, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility reported a census of 75 residents. Findings include: During a continuous observation 6/2/25 beginning at 11:50 AM, Staff E, dietary staff, served residents drinks going from table to table in the dining room during lunch service. Observed Staff E place her hand on the rim of a drinking glass and place the glass down on the table in front of a resident. Staff E placed this same hand in a trash bag attached to the serving cart more than once, then used this hand to prepare drinks for residents, placing her hand on the rim of the drinking cup for several residents without sanitizing her hands. Staff E put this same hand on the spoon portion of a spoon, not the handle, and placed the spoon into a coffee cup and handed this to a resident. Staff E placed her hand in the trash bag several times during…

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 interview, and policy review the facility failed to document a resident's transfer to the hospital, physician and family notification, and a bed hold for 1 of 3 residents reviewed. (Resident #7) The facility reported a census of 75 residents. Findings include: The Minimum Data Set (MDS) for Resident #7 dated 4/10/25, included diagnoses of Non-Alzheimer's Dementia, stroke, and heart failure and a Brief Interview for Mental Status score of 99 indicating the resident was not able to complete the assessment due to severe cognitive impairment. Resident #7's Clinical Census documented the resident on hospital leave 1/27/25 - 2/12/25. The Progress Notes for Resident #7's revealed the following: 1/28 - 2/11/25 - hospitalized . 2/3/25 at 5:43 PM - resident was admitted to the hospital. 2/12/25 at 1:20 PM - resident returned. Review of Resident #7's Progress Notes 1/27/25 - 2/12/25 lacked documentation of the resident's transfer to the hospital, physician and family notification of transfer to the hospital, and bed hold completed. Resident #7's hospital…

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 interview, and policy review the facility failed to accurately complete a Minimum Data Set (MDS) Assessment by not identifying a resident had a serious mental illness as considered by the state level II Preadmission Screening and Resident Review (PASRR) for 1 of 16 residents (Resident #34) reviewed. The facility reported a census of 75 residents. Findings include: The MDS for Resident #34, dated 3/22/25, included diagnoses of Psychotic Disorder, Anxiety Disorder, and depression and documented the resident was not currently considered by the state level II PASRR process to have serious mental illness. Resident #34's Notice of PASRR Level II Outcome dated 1/20/24, revealed an approved PASRR Level II outcome with the determination explanation of the resident meets PASRR criteria for serious mental illness for the diagnosis of Major Depressive Disorder. Facility policy, Conducting an Accurate Resident Assessment reviewed/revised 1/2025 revealed that all residents receive an accurate assessment and correctly document the resident's medical,…

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 submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 4 residents reviewed with mental health diagnosis and medications (Resident #31). The facility reported a census of 75 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #31 was admitted to the facility on [DATE], a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact and diagnoses of cancer, heart failure, peripheral vascular disease, renal insufficiency, alcoholic cirrhosis of liver, cannabis abuse, Werrnicke's encephalopathy (serious brain disorder caused by a deficiency of thiamine. Often associated with chronic alcohol abuse) delusional disorders, Non-Alzheimer's Dementia, anxiety disorder, depression, and psychotic disorder. The MDS indicated Resident #31 is taking the following pharmacological classed medications; antipsychotics, antianxiety,…

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 interview, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 20 residents reviewed (Resident #25). The facility reported a census of 75 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #25 scored 14 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS included diagnoses for Resident #25 of debility, cardiorespiratory conditions, heart failure, diabetes mellitus, respiratory failure and need for assistance with personal care. The resident was dependent on staff for toileting hygiene and the resident did not perform the activity of toilet transfer. The resident was frequently incontinent of urine and always incontinent of bowel in the look back period. The resident was not on a urinary or bowel toileting program. The Care Plan, with an initiation date of 6/24/22, included the resident had a self…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to accurately reflect status of 1 of 20 (Resident #48) residents reviewed. The facility reported a census of 75. Findings include: Review of Resident #48's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, (indicating a resident is unable to complete the interview due to not being able to understand the questions, unable to respond, or other barriers to conducting the interview). The MDS indicated, Resident #48's preferred language is Bosnia and an interpreter is needed to communicate. Resident #48's diagnoses included hypertension, Non-Alzheimer's Dementia, anxiety disorder, and depression. The MDS also indicated Resident #48's mobility assistance for transfers required substantial/maximal assistance and supervision or touching assistance for walking with a walker. Review of Resident #48's Electronic Health Record (EHR) revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interviews, staff interviews and policy review, the facility failed to ensure the resident's environment was free from hazards and each resident received adequate supervision to prevent accidents and ensure safety for 2 of 4 residents reviewed (Resident #75 and #5). The facility reported a census of 75 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #75 scored 15 on the Brief Interview for Mental Status (BIMS) indicting intact cognition. Diagnoses for the resident included medically complex conditions, atrial fibrillation, hypertension, asthma, chronic obstructive pulmonary disease (COPD), and respiratory failure. The Care Plan, initiated 5/16/25, included Resident #75 may smoke with supervision per smoking assessment. Resident must have supervision by nursing with removing his oxygen and monitoring signs/symptoms of low oxygen saturation. The facility Safe Smoking Assessment Form, dated 5/16/25 for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure knowledge and techniques necessary to care for residents' medication management in a timely manner for 1 of 5 residents reviewed for unnecessary medications, chemical restraints/psychotropic medications and medication regimen review (Resident #31). The facility reported a census of 75. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #31 was admitted to the facility on [DATE], a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact and diagnoses of cancer, heart failure, peripheral vascular disease, renal insufficiency, alcoholic cirrhosis of liver, cannabis abuse, Werrnicke's Encephalopathy (serious brain disorder caused by a deficiency of thiamine. Often associated with chronic alcohol abuse) delusional disorders, Non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. The MDS indicated Resident #31 is taking the following…

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

Based on observation, staff interview, and policy review, the facility failed to safely store and label resident's medications. The facility reported a census of 75 residents. Findings include: Observation of a medication cart on 6/3/25 at 10:31 AM, revealed a medicine cup with approximately 12 pills, labelled with Resident #31's name. Staff B, Certified Medication Aide (CMA) stated He likes his meds later. Continued observation revealed unsealed/opened stock medications that were not dated with the date the bottle was opened. On 6/3/25 at 10:40 AM, the Director of Nursing (DON) was notified of undated stock medications. The DON observed the bottles in the medication cart and acknowledged the failure to indicate the opening dates. The DON stated the facility follows the Pharmacy's recommendations for labeling medications. During an interview on 6/5/25 at 3:35 PM, the DON stated residents medications should not be set up and left in the medication cart. The DON's expectations are meds to be prepared at the time the medications are administered. If residents prefer their medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility policy review, the facility failed to provide assessments, obtain orders, or follow up with physician on a resident with an identified central line for 1 of 3 residents (Resident #2) reviewed for assessment and intervention. The facility reported a census of 65 residents. Findings include: The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #2 admitted to the facility from an acute hospital on 3/20/25. A Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicated intact cognition. Resident #2 diagnoses included atrial fibrillation, cirrhosis of liver, End Stage Renal Disease (ESRD), viral hepatitis, Diabetes Mellitus, immunodeficiency, and dependence on renal dialysis. The admission Assessment, dated 3/20/25, revealed Resident #2 required Hemodialysis for ESRD and had an arteriovenous left sided fistula. admission Assessment lacked identification of central or intravenous lines present upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, clinical record review, staff training schedule review, and facility policy review, the facility failed to ensure the behavioral health program was effective for a resident with history of Substance Use Disorder (SUD), when direct care staff reported a lack of training for SUD, resident plan of care lacked plans to prevent substance use in the facility, or interventions for suspected or identified substance use by resident, and lacked plans for the potential of an overdose emergency, when Resident #1 displayed erratic behaviors resulting in hospitalization with positive Methamphetamines drug test for 1 of 3 residents (Resident #1) reviewed for behavioral health. The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) Discharge Assessment, dated 4/24/25, for Resident#1 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS revealed that Resident #1 had verbal behaviors 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, clinical record review, staff interviews, and facility policy review the facility failed to fully review and revise the comprehensive Care Plans when a resident had a change in advance directives and smoking status for 6 of 24 residents reviewed (Residents #10, #21, #26, #34, #45, and #61). The facility reported a census of 61 residents. Findings include: 1. Review of Resident #10's Iowa Physician Orders for Scope of Treatment (IPOST), dated [DATE], revealed Resident #10 indicated in the event she had no pulse and was not breathing, Do Not Attempt Resuscitation (DNR). Review of Resident #10's Care Plan dated [DATE], indicated Resident #10 requested Full Code status, indicating providing emergency measures as appropriate, including CPR (Cardiopulmonary Resuscitation). 2. Review of Resident #34's IPOST, dated [DATE], indicated DNR code status. Review of Resident #34's Care plan dated [DATE], revealed Full Code status. 3. Review of Resident #45's IPOST, dated [DATE], indicated Full Code/CPR 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, resident and staff interview, record and policy review, the facility failed to provide services to protect the resident from accidents or hazards by transferring a resident in a wheelchair without foot pedals (#20), not providing supervision or apron during resident smoking breaks for 3 of 3 residents (#21, #26, and #61), and not retrieving smoking materials from 3 of 3 residents (#21, #26, and #57). The facility reported a census of 61. Findings include: 1) On 12/02/24 at 11:21 AM, Resident #57 stated he smoked and was observed with his cigarettes and lighter in his shirt pocket. He stated he keeps his cigarettes with him because the facility would not replace lost cigarettes. The Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of depression, hypertension (HTN), Parkinsons (brain conditions that cause slowed movements, stiffness, and tremors),…

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

Based on observations, record review, staff interview, and policy review, the facility failed to ensure food prepared and maintained at the appropriate temperature as well as dishes and utensils cleaned in a sanitary manner related to incomplete food and dishwasher logs. The facility reported a census of 61. Findings include: 1. The Food Temperate Record logs reviewed for the months of September, October, and November. From 9/1/25 thru 10/5/24, 24 meals were incomplete or did not have any food temperatures recorded out of 105 meals. From 10/6/24 thru 11/2/24, 24 meals were incomplete or did not have any food temperatures recorded out of 84 meals. From 11/3/24 thru 11/30/24, 13 meals were incomplete or did not have any food temperatures recorded out of 84 meals. A food thermometer and alcohol wipes were observed in the food prep area for staff use. 2. The Dishmachine Quality Assurance Forms reviewed for the months of October and November. From 10/7/24 thru 11/3/24, 8 out of 84 meals did not have verification that the dischmachine chemical sanitizer reached 50 ppm or greater. From…

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, policy review, and staff interview, the facility failed to ensure food is stored in a sanitary manner to prevent contamination and foodborne illness. The facility reported a census of 61. Findings include: Initial kitchen tour completed on 12/2/24 at 10:00 AM revealed the following: a. Walk-in freezer floor with excess debris (food crumbs, several small food items, packing tape from delivery boxes) b. Fryer, which was not in use, full of oil with no cover c. Plastic cereal containers with no label or dates During an interview on 12/2/24 at 11:00 AM, the Certified Dietary Manger (CDM) reported there are no required daily or weekly cleaning checklists which staff completed. A general checklist of cleaning needs is located on the whiteboard as staff enters the kitchen. Walk-in cooler and freezer floors are swept out as needed. When not in use, the fryer should have a sheet pan over the oil to protect from contamination. The CDM acknowledged the lack of labels for the cereal containers since the cereals are not stored in their original packaging. The policy Food…

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 employee file review, staff interview, and policy review, the facility failed to complete a criminal record check and dependent adult/child abuse registry check prior to an employee's rehire date for 1 of 5 employee files reviewed. The facility reported a census of 61. Findings include: Employee record review of Staff E, Registered Nurse, showed a rehire date of 9/9/24. Staff E's updated Single Contact License and Background Check was initiated on 9/4/24 at 3:57 PM. The Criminal History Background Check indicated further research required and to await Division of Criminal Investigation's (DCI) final response. Staff E's employee record did not show that any further follow-up completed prior to working with residents. The facility initiated another Single Contact License and Background Check on 11/11/24 at 3:57 PM. The background check process was completed on this date. However Staff E had been working with residents from 9/9/24-11/11/24. During an interview on 12/5/24 at 10:45 AM, the Provisional Administrator acknowledged that the criminal and dependent adult/child abuse…

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 ensure the Care Plan addressed high risk medications such as insulin and antidepressants for 1 of 5 residents reviewed for medications(Resident #29). The facility also failed to follow the Care Plan with regard to smoking materials for 1 of 4 residents reviewed for smoking (Resident #57). The facility reported a census of 61 residents. Findings include: 1. The admission Minimum Data Set(MDS) assessment tool, dated 10/19/24, listed diagnoses for Resident #29 which included diabetes, anxiety, and depression. The MDS stated the resident received insulin (a medication used to lower blood sugar), antianxiety medications, and antidepressant medications and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, which indicated intact cognition. The December 2024 Medication Administration Record(MAR) listed the following: a. an 11/29/24 order for Lispro insulin(a type of fast-acting insulin) per sliding scale…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review the facility failed to provide physician orders related to code status and accurately document in clinical records so that staff know immediately what action to take or not take when an emergency arises for 2 of 24 residents reviewed (Residents #10 and #34). The facility reported a census of 61 residents. Findings include: 1. Review of Resident #10's Iowa Physician Orders for Scope of Treatment (IPOST), dated [DATE], revealed Resident #10 indicated in the event she had no pulse and was not breathing, Do Not Attempt Resuscitation (DNR). Review of Resident #10's Care Plan dated [DATE], indicated Resident #10 requested Full code status, indicating providing emergency measures as appropriate, including CPR (Cardiopulmonary Resuscitation). Review of Resident #10's Electronic Health Record (EHR) indicated on the page header, Resident's code status as Full code/CPR Review of Resident #10's Physicians order dated [DATE] indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and policy review, the facility failed to consistently perform required pre-dialysis and post-dialysis assessments for 1 of 1 resident (#35). The facility reported a census of 61. Findings include: On 12/02/24 at 2:34 PM, Resident #35 stated staff had not routinely performed assessments before or after her hemodialysis treatments. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of anemia, hypertension, End-Stage Renal Disease (ESRD), Diabetes Mellitus (DM), epilepsy, psychotic disorder, and Non-Alzheimer's dementia. It also revealed the resident required maximum assistance with eating and oral hygiene, and was dependent with all other Activities of Daily Living (ADLs). It indicated the resident received dialysis within previous 14 days. The Care Plan dated 7/10/22 included a dialysis focus and directed staff 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.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to provide resident care needs for 1 of 1 residents reviewed for staffing(Resident #51). The facility reported a census of 61 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 11/5/24, listed diagnoses for Resident #51 which included hemiplegia(one-sided weakness), anxiety, and diabetes, and stated the resident was dependent on staff for toilet transfers and toileting hygiene. The MDS stated the resident was occasionally incontinent of urine and listed his Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Call Lights: Accessibility and Timely Response, reviewed 11/2024, stated all staff members who saw or heard an activated call light was responsible for responding and stated if the staff member could not provide what the resident desired, the appropriate personnel should be notified. Care Plan entries, dated 12/12/22, stated the resident had the potential for impaired skin integrity related…

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

Based on observation, resident and staff interview, record review, and policy review, the facility failed to implement infection control practices to prevent urinary tract infection (UTI) for 1 of 1 resident (#28). The facility reported a census of 61. Findings include: On 12/02/24 at 2:07 PM, the urine in the resident's indwelling catheter was noted to be opaque and cloudy. The Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of obstructive uropathy (urine unable to drain normally), acute renal failure, and anemia. It indicated the resident required moderate assistance with personal hygiene and was dependent with toileting hygiene. It also revealed the resident had developed a urinary tract infection (UTI) while a resident. The Care Plan dated 7/05/24 included an indwelling catheter focus and directed staff to position the catheter bag and tubing below the level of the bladder and away from entrance room door. The Electronic Health Record (EHR) Progress Notes indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record (EHR) review, staff interview, and policy review, the facility failed to ensure 1 of 5 residents reviewed for immunizations was provided up to date pneumococcal vaccinations (Resident #45). The facility reported a census of 61 residents. Findings include: Resident #45's Face Sheet listed her age as [AGE] years old. The original admission date listed as 12/6/22. The Immunization Record for Resident #45 lacked documentation on the resident's pneumococcal vaccination status. On 7/25/23, Resident #45 signed the Pneumococcal Vaccine Consent Form and Wavier, which indicated an interest in receiving the vaccine. The EHR lacked documentation if the vaccine had been administered as requested. During an interview on 12/5/24 at 2:00 PM , the Provisional Administrator acknowledged the lack of documentation for Resident #45's pneumococcal vaccination status and if the vaccine was administered in 2023. The Infection Prevention and Control Program document reviewed/revised on 7/2024 states…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record (EHR) review, staff interview, and policy review, the facility failed to ensure 2 of 5 residents reviewed for immunizations were provided up to date Covid vaccinations (Resident #2 and Resident #45). The facility reported a census of 61 residents. Findings include: 1. Resident #2's Face Sheet listed her age as [AGE] years old. The original admission date listed as 9/27/14. The Immunization Record for Resident #2 documented the last Covid vaccination was administered on 11/29/22. The EHR lacked documentation if an updated Covid vaccine was offered or administered in 2023. 2. Resident #45's Face Sheet listed her age as [AGE] years old. The original admission date listed as 12/6/22. The Immunization Record for Resident #45 documented the last Covid vaccination was administered on 12/21/2021. The EHR lacked documentation if an updated Covid vaccine was offered or administered in 2022 or 2023 During an interview on 12/5/24 at 2:00 PM , the the Provisional Administrator acknowledged…

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 interviews and laboratory interview, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 3 residents reviewed (Residents #2, #3). The facility failed to obtain labs per Physician orders. The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #2 dated 1/13/24 identified a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS included diagnoses of coronary artery disease, heart failure (inability for the heart to pump enough blood), hypertension (high blood pressure), end stage renal disease (kidney), diabetes mellitus, acute and chronic respiratory failure with hypoxia (low level of oxygen in body tissue), pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and right side of the heart), and chronic obstructive pulmonary disease(COPD)(chronic inflammatory lung disease that causes obstructive air flow from the lungs). The February…

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, observations, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #3) for falls. The facility reported a census of 55 residents. Findings include: The Quarterly MDS assessment for Resident #3 dated 5/24/24, BIMS assessment was not completed. The Staff Assessment for Mental Status indicated severely impaired decision making. The MDS identified Resident #3 was independent with bed mobility and transfers. The MDS documented Resident #3 used a walker, and had impairment on both lower extremities. The MDS documented diagnoses of anemia, coronary artery disease, hypertension, hip fracture, Alzheimer's disease and Non-Alzheimer's disease. An Incident Report dated 5/17/24 at 9:15 PM documented staff found Resident #3 laying on the floor at the end of hall 3. Resident stated, I was walking around and I fell. Resident #3 was laying on his back with his legs stretched out in…

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 interviews, and policy review the facility failed to provide appropriate incontinence care for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 55 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident #4 dated 3/4/24 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS identified Resident #4 was dependent on staff for toileting hygiene and transfers.The MDS included diagnoses of heart failure (inability for the heart to pump enough blood), hypertension (high blood pressure), renal disease (kidney), diabetes mellitus, and overactive bladder. The MDS identified Resident #4 was always incontinent of bowel and bladder. The Care Plan with target date 9/1/24 revealed Resident #4 had the potential for infection related to history of UTIs and pneumonia with initiated date of 6/7/2022. The Care Plan directed staff to monitor/document/report to the…

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

Based on observations, record review, staff interviews, and policy review, the facility failed to provide oxygen according to physician orders for 3 of 4 residents reviewed (Residents #2, #6, and #7) for respiratory services. The facility reported a census of 55 residents. Findings Include: 1. The Annual Minimum Data Set (MDS) assessment for Resident #2 dated 12/4/23 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of coronary artery disease, heart failure (inability for the heart to pump enough blood), hypertension (high blood pressure), end stage renal disease (kidney), diabetes mellitus, acute and chronic respiratory failure with hypoxia (low level of oxygen in body tissue), pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and right side of the heart), and chronic obstructive pulmonary disease(COPD)(chronic inflammatory lung disease that causes obstructive air flow from the lungs).The MDS documented Resident #2 was on oxygen therapy while a resident at 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, hospital record review, staff interview and policy review, the facility failed to arrange and/or provide transportation services to Physician appointments for 2 out of 3 resident reviewed (Residents #2, #3). The facility reported a census of 55 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 1/13/24 identified a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS identified Resident #2 was dependent on staff for bed mobility and chair/bed to chair transfers. The MDS documented Resident #2 used a wheelchair. The MDS included diagnoses of coronary artery disease, heart failure (inability for the heart to pump enough blood), hypertension (high blood pressure), end stage renal disease (kidney), diabetes mellitus, acute and chronic respiratory failure with hypoxia (low level of oxygen in body tissue), pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and right side of the heart), and chronic obstructive…

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 give medications as directed per the physicians orders for 2 or 4 residents reviewed. (Resident #1 and Resident #6). The facility reported a census of 56 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had diagnoses for which included anemia, hip fracture, cerebrovascular accident, seizure disorder, traumatic brain injury anxiety and depression. The MDS documented the resident scored a 3 on the Brief Interview for Mental Status (BIMS). A score of 3 identified severely impaired cognitive abilities. The MDS assessment documented the resident required substantial to maximal assistance with activities of daily living. The Medication Discharge report signed and dated by the physician on 1/11/24 at 10:50 a.m., instructed staff to apply a Lidocaine (pain) topical pad (4%) transdermal every day. The Electronic Order transmitted to the pharmacy dated 1/11/24, instructed staff 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 and staff and resident interview, the facility failed to provide two baths a week as directed for 3 out of 4 residents reviewed (#1, #2, and #3). The facility reported a census of 56 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had diagnoses for which included anemia, hip fracture, cerebrovascular accident, seizure disorder, traumatic brain injury anxiety and depression. The MDS documented the resident scored a 3 on the Brief Interview for Mental Status (BIMS). A score of 3 identified severely impaired cognitive abilities. The MDS assessment documented the resident required substantial to maximal assistance with showers/bathing. Review of electronic documentation of task completion (bathing) for Resident #1 revealed the facility failed to provide baths between: *December 21,2023 and December 28, 2023 *January 15, 2024 and January 22, 2024 *February 5, 2024 and February 12, 2024. 2. The MDS assessment dated [DATE],…

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, policy review, and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility identified a census of 57 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's annual survey 5/31/22 and 8/16/23, complaint investigations completed 8/16/23 and 10/31/23, and the current complaint investigations. The repeat deficiencies cited included: F658 cited 5/31/22, 8/16/23, 10/25/23, and during the current survey F684 cited 8/16/23, 10/25/23 and during the current survey. F690 cited 8/16/23 and during the current survey F725 cited 8/16/23, 10/25/23 and during the current survey F761 cited 10/25/23 and during the current survey F880 cited 8/16/23 and during the current survey A Quality Assurance and Performance Improvement 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 observations, staff interviews, and policy review, the facility failed to ensure treatment and medication carts kept locked when not attended by staff for 3 of 4 treatment carts observed. The facility reported a census of 57 residents. Findings include: Observations revealed the following: a. On 12/11/23 at 12:25 PM, a treatment cart on the 400-500 Hall sat by the wall with drawers facing outward, and cart unlocked. The treatment cart drawers contained various medicated creams and treatments, such as wound cleanser, dakin's solution, ascetic acid solution, Nystatin, and betadine solution b. On 12/12/23 at 10:20 AM the treatment cart on the 200 hall appeared to be locked, however when pulled on the drawer the drawer opened. At the time, Staff E, Registered Nurse (RN) reported it's a manufacturer error. If the lock button is pushed in, it is expected the cart is locked, but if the drawer isn't pushed all the way in it won't lock. Staff E stated the staff assigned to the 200 hall cart is an agency staff and she wouldn't know that. Staff E didn't know what kind of training 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, observation, staff interview, and policy review, the facility failed to ensure staff performed hand hygiene prior to or after completion of treatment and dressing change, failed to cleanse a wound after a soiled dressing removed and before application of new treatment products per physician's orders, and failed to change gloves when went from a dirty to a clean area for one of two resident treatments observed (Resident #11). The facility also failed to change gloves and sanitize hands after performed incontinence care and before touched other objects such a bed control or catheter for two of three residents observed for incontinence care (Resident #11 and #12) The facility staff also failed to wear gloves when a blood sugar performed for one of two blood sugar checks observed. The facility reported a census of 57 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 had diagnoses of septicemia (infection in the blood)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review, the facility staff failed to follow physician's orders to cleanse a wound after a soiled dressing removed and before application of new treatment products, failed to ensure staff performed hand hygiene prior to or after completion of treatment and dressing change, and failed to change gloves when going from a dirty to a clean area for one of two resident treatments observed (Resident #11). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 had diagnoses of septicemia (infection in the blood) and an open wound on her left buttock. The MDS indicated the resident had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) and took an antibiotic during the 7-day look-back period. The Care Plan initiated 5/17/23 and revised on 10/17/23 revealed the resident had a stage 4 pressure ulcer on her sacrum related 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 record review, observation, resident and staff interviews, pharmacy interview, and policy review, the facility failed to ensure an Albuterol inhaler was reordered from pharmacy in a timely manner for one of five residents reviewed for medication administration (Resident #9). The facility also failed to follow physician's orders for obtaining daily weights, failed to notify the physician of significant weight gains, and failed to implement standards of care for resident who had diagnoses of congestive heart failure of one of five residents reviewed for assessment/intervention (Resident #9). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had diagnoses of Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) (emphysema). The MDS revealed the resident on oxygen (O2) and took a diuretic medication during the 7-day look-back period. The MDS documented the resident had a Brief Interview 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 clinical record review, observation, staff interview, and policy review the facility failed to provide incontinence care to prevent cross contamination and infection for two of three residents observed for incontinence care (Resident #11 and #12). The facility reported a census of 57 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 had diagnoses of Alzheimer's disease and septicemia (infection in the blood). The MDS indicated the resident had a catheter, and took an antibiotic during the 7-day look-back period. The MDS revealed the resident had dependence on staff for toileting. The Care Plan initiated 5/10/23 and revised on 11/21/23 revealed the resident had self-care deficit in activities of daily living (ADL's) related to Alzheimer's disease and a recent hospitalization due to severe sepsis. The Care Plan directed staff to provide assistance of one for toileting, and use a Hoyer and two staff for transfers. During observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and policy review, the facility staff failed to ensure resident's call light within reach for two of nine residents reviewed for call light response and accessibility (Resident #11 and Resident #12). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 had diagnoses of Alzheimer's disease. The MDS revealed the resident had a Brief Interview for Mental Status score of 5, indicating cognition severely impaired. The MDS documented the resident dependent for toileting, and required substantial to maximal assistance for transfers. The MDS documented the resident had two or more falls since admission. Resident #11's Care Plan initiated 5/17/23 and revised on 11/21/23 revealed the resident had a risk for falls related to gait and balance problems, and unaware of safety needs. The Care Plan directed staff to ensure the resident's call light within reach, encourage the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview, the facility failed to provide two baths a week as directed for 4 out of 5 residents reviewed (#6, #7, #8 and #13). The facility reported a census of 73 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had diagnoses for which included heart failure, hypertension, anxiety, depression and morbid obesity. The MDS documented the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident to be cognitively intact. The MDS assessment documented the resident with no rejection of cares, and the bathing activity itself did not occur and the entire 7-day look back period with this assessment. Review of electronic documentation of task completion for Resident #6 revealed the facility failed to provide baths in September on 9/27/2023 and for the dates October on 10/4/2023, and 10/7/0223. In an interview on 10/17/2023 at 3:50 p.m., Resident #6 stated that they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interview the facility failed to complete bathing/showers as required for 4 of 5 residents reviewed. (#6, #7, #8 and #13) The facility census was 73 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had diagnoses which included heart failure, hypertension, anxiety, depression and morbid obesity. The MDS documented the resident scored a 15 on the Brief Interview for Mental Status (BIMS). A score of 15 identified cognitively intact. The MDS assessment documented the resident with no rejection of cares, and the bathing activity itself did not occur and the entire 7-day look back period. Review of electronic documentation of task completion for Resident #6 revealed the facility failed to provide baths in September on 9/27/2023 and in October on 10/4/2023, and 10/7/0223. In an interview on 10/17/2023 at 3:50 p.m., Resident #6 stated that they did not receive their bath/showers on the above dates and would…

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, policy review and staff interview, the facility failed to ensure the medication cart was locked on 3 occasions when the Certified Medication Aide (CMA)/Nurse responsible for the cart was not in sight. The facility reported a census of 73 residents. Findings include: 1. Observation 10/25/23 at 10:50-10:57 a.m. revealed the medication cart was unlocked and unoccupied just outside room [ROOM NUMBER] in the 100 hallway. At 10:57 a.m., Staff G, Licensed Practical Nurse (LPN) approached the cart and acknowledged it had not been locked as expected. Staff G, LPN stated she was responsible for the medication cart and confirmed and demonstrated that the drawers to the cart were able to be opened when the cart not locked and the drawers contained medications. 2. Observation on 10/10/23 at 12:12 p.m., - 12:20 p.m., revealed the medication cart was unlocked and unattended/unoccupied in the 200 hallway. At 12:20 p.m., Staff J, LPN was approached by this surveyor and was informed that the medication cart…

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 and procedure review and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 5 resident reviewed. (Resident #11). The facility identified a census of 73 residents. Findings include: 1. The Significant Change in Status Minimum Data Set (MDS) for Resident #11, with an assessment reference dated 9/25/2023, documented diagnosis for which included Cancer, Osteoporosis, Malnutrition, Depression, Anxiety, Bipolar Disorder, and restlessness and agitation. The MDS revealed the resident with short and long term memory problems, severely impaired for decision making abilities, verbal and other behavioral symptoms directed towards others, and required total assist of two staff members for all aspects of daily living. The Care Plan with a initiated date 4/23/2022, stated the resident has impaired cognitive function and/or impaired though processes as evidenced by short/long term memory deficit, impaired decisions making and/or…

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 notify the facility physician of a urinary analysis that was not collected in a timely manner for 1 of 4 residents reviewed (Resident #5). The facility reported a census of 73 residents. Findings include: 1. The admission Minimum Data Set (MDS) dated [DATE], for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 13 for which indicated no impaired cognition. The MDS documented the resident with verbal behavioral symptoms towards others, and required supervision of set-up assistance for transfers, locomotion on and off the unit, toilet use and personal hygiene and was frequently incontinent of bladder. The MDS revealed the resident had diagnoses which included muscle weakness and personal history of urinary tract infections and was on an antibiotic in the last 7 days. The Encounter Note dated 7/31/2023 at 3:54 p.m., documented New admission to the facility. History includes urinary incontinence. Past Medical History 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.

Based on clinical record review, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents are reported immediately to management staff per facility policy and to the Iowa Department of Inspection and Appeals within two hours. (Resident #11). The facility reported a census of 73 residents. Findings include: 1. The Significant Change in Status Minimum Data Set (MDS) for Resident #11, with an assessment reference dated 9/25/2023, documented diagnoses including Cancer, Osteoporosis, Malnutrition, Depression, Anxiety, Bipolar Disorder, and restlessness and agitation. The MDS revealed the resident with short and long term memory problems, severely impaired for decision making abilities, verbal and other behavioral symptoms directed towards others, and required total assist of two staff members for all aspects of daily living. The Care Plan with a initiated date 4/23/2022, stated the resident has impaired cognitive function and/or impaired though processes as evidenced…

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 failed to provide care and services according to accepted standards of clinical practice for 2 of 3 residents reviewed (Resident #2 and #12) and failed to give medications as directed per the physicians orders during the medication pass for (Resident #15 and Resident #16). The facility failed to assure Resident #2 attended follow up cardiac appointment as ordered following a May hospitalization. Resident's appointment was canceled on 6/1/23 for lack of transportation and 6/7/23 due to lack of communication. Resident was again hospitalized and on 8/14/23 the resident was seen for a follow up cardiac appointment, however no record of her medications was sent to the clinic despite their request. Resident #12 had an appointment with the wound clinic on 9/8/2023, Resident #12 was late for the appointment and was not able to be seen. The facility reported a census of 73 residents. Findings include: 1. According to the Quarterly…

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 record review and staff interview, the facility failed to do an annual performance evaluation for 1 of 6 employee records reviewed. (Staff A). The facility identified a census of 73 residents. 1. Record Review on 10/23/2023 at 11:00 a.m., revealed Staff A, Certified Nursing Assistant (CNA) had a hire date of 5/03/2017. *A Performance Evaluation dated 3/26/2021, revealed an annual evaluation, signed and dated by Staff A on 5/28/2021. The Personnel record lacked any documentation of Annual Performance Evaluations completed for 2022 and 2023. Interview on 10/24/2023 at 10:00 a.m., the facility Interim DON (corporate nurse), confirmed and verified that the personnel record lacked annual performance evaluations for 2022/2023 and that the expectations are that the performance evaluations to be completed yearly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, and staff interview, the facility failed to treat each resident with respect and dignity by staff speaking to residents in a derogatory manner, confining residents to their rooms with no clinical indication, and by not following the appropriate plan of care when toileting assistance was requested for 4 of 24 residents reviewed (#37, #56, #71, #230). The facility reported a census of 79. Findings include: 1. Resident #37's Quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderately impaired cognition. On 7/24/23 at 4:25 pm, an observation revealed Resident #37 ambulating down the hall with her walker and asked to get some Kleenex. Staff Y, Certified Nurse Aide (CNA) stated OK, I'll get you but did not turn around to face the resident. The resident repeated her request and added it was for she and her roommate. Staff Y said, ok without facing the resident. Another staff member heard the request…

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, policy review, and staff interview, the facility failed to ensure residents had a clean and homelike environment in common areas of the facility and hallways by ensuring carpeting and tiling were clean and in good repair. The facility reported a census of 79 residents. Findings included: 1. An observation on 7/25/23 at 10:58 a.m. revealed the carpeting at the main nursing station, throughout halls 100, 200, and 300, and in the TV area covered with multiple dark stains, ranging in size up to 2 feet in diameter. Observations on the following days revealed the stains remained: 7/26/23, 7/27/23, 7/31/23, 8/1/23. The facility policy Routine Cleaning and Disinfection, dated 4/2019, stated the facility would ensure the provision of routine cleaning in order to provide a safe and sanitary environment. The policy directed staff to clean horizontal surfaces on a regular basis and when soiling and spills occurred. On 8/10/23 at 8:38 a.m., the Administrator stated after a comment was made about 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, resident and staff interview, and policy review, the facility failed to provide Activities of Daily Living (ADLs) assistance including bathing, positioning, oral cares, incontinence cares and clean clothing for 6 of 12 residents reviewed (#32, #46, #55, #56, #63, & #275). The facility reported a census of 79 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool for Resident #32, dated 6/19/23, listed diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and depression. The MDS stated the resident required extensive assistance of 2 staff for personal hygiene and listed her Brief Interview of Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. Continuous observation on 7/26/23 revealed the resident in bed from 7:15 a.m. through 8:39 a.m. At 8:05 a.m., staff delivered the resident's breakfast and she ate it in bed. At 8:39 a.m. Staff L, Certified Nursing Assistant (CNA) and Staff M, CNA…

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 ensure enough staffing to ensure timely call light response times for 5 of 18 residents reviewed (Resident #24, #33, #40, #65, and #177) The facility reported a census of 79 residents. Findings: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/26/23, listed diagnoses for Resident #24 which included coronary artery disease, kidney disease, and diabetes. The MDS stated the resident required extensive assistance of 2 staff for bed mobility, dressing, toilet use, and personal hygiene, and depended completely on 2 staff for transfers. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. In an interview on 7/24/23 at 1:47 p.m., Resident #24 stated call light wait times were horrible. She stated yesterday she had her call light on for hours and no one came in. She stated she timed it with the clock in her room. A Care Plan entry, dated 5/20/22, stated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #60's Physicians Orders included Oxycodone 5 mg every 6 hours as needed for moderate to severe pain 11/21/22 to 2/14/22, then Oxycodone 5 mg every 8 hours as needed for moderate to severe pain 2/14/23 to 2/16/23, then Oxycodone every 6 hours as needed for moderate to severe pain with a start date of 2/16/23. A Misappropriation of Medication Investigation dated 3/8/23 documented Staff U Licensed Practical Nurse (LPN) talked to the Director of Nursing (DON) about a card of Oxycodone for Resident #60 (in the hospital at the time). Staff V Certified Medication Aide (CMA)/Scheduler told Staff U it was in the DON's office. Staff V said she would come in, but did not. Staff U and the DON went into the scheduling office to see if they could locate the blister pack. They found a blister pack in a file cabinet, with no narcotic sheet present. The blister pack was empty. The DON was uncertain if it was the bubble pack in question. Staff U placed a couple more calls to see if Staff V was coming in to produce 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 resident interviews, staff interview and observations, the facility failed to provide ready access to resident's personal funds managed by the facility for 3 of 12 residents sampled. (#4, #12 & #55) Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #12 dated 6/28/23 identified a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The Care Plan of Resident #12, last review date of 4/7/23 failed to reveal any documentation regarding a Personal Funds Account with the facility. On 7/24/23 at 11:23 am Resident #12 stated she is supposed to receive $50 a month but the facility never wants to give it to her. She stated when she knows she has a shopping trip coming up she will make a request for the money but she it is always delayed. She described this as very aggravating. She stated there is only 1 staff member who can access the money for any of the residents. On 7/26/23 at 9:50 am, signage was observed on the door to facility business…

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, record review, and policy review, the facility failed to maintain accurate and complete accounting records by failing to credit personal fund account deposits in an acceptable timeframe for 1 of 3 residents (#2). The facility identified a census of 79 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. It revealed medical diagnoses of anxiety, depression, Amyotrophic Lateral Sclerosis (Lou Gehrigsdisease - a neurologic disease that causes the nerves responsible for muscle movement to degenerate and die). On 8/02/23 at 12:30 PM, Resident #2's family member stated that the facility failed to properly credit the resident's personal trust fund for deposits on 5/25/23 and 7/25/23 and failed to credit billing statements for 7/7/23. A billing statement dated 6/28/23 included an upcoming resident liability charge due on 7/01/23. An endorsed check revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to notify the physician and family of a resident's change in condition for 1 of 4 residents reviewed (Resident #77). The facility reported a census of 79 residents. Findings include: 1) According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #77 scored 7 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The resident required supervision with transfer and ambulation. The resident's diagnoses included Alzheimer's disease. The Care Plan revised 7/12/22 identified the resident had (potential for) impaired skin integrity and was at risk for edema, skin/tissue color changes, sensitivity towards heat/cold, swelling and pain. The interventions included: a. Avoiding scratching and keeping hands and body parts from excessive moisture, b. Keeping fingernails short, c. Encouraging good nutrition and hydration in order to promote healthier skin, d. Keeping skin clean and dry, e. Using lotion 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 record review, staff interview, and facility policy review, the facility failed to assure a resident's contact person was notified when a resident chose to leave against medical advice (AMA) for 1 resident reviewed (Resident #224). The facility also failed to implement a discharge planning process for Resident #63. The facility reported a census of 79 residents. Findings include: 1. The Progress Notes dated 7/12/23 at 6:31 p.m. documented the Resident #224 arrived via ambulance around 2:30 p.m. Paperwork received. Faxed discharge papers from the hospital to the primary care provider (PCP) and pharmacy. The resident used a wheelchair, able to propel self, and had bilateral above the knee amputations. Resident #224's clinical record included Hospital Discharge records. A Hospitalist Progress Note dated 7/10/23 contained documentation a psychiatric evaluation noted the resident not competent to make his own decisions, and listed a family member as his primary contact. The Baseline Care Plan completed…

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 records, staff interviews and facility policy review, the facility failed to analyze the cause of falls and provide interventions to prevent further falls for 1 of 3 residents (Resident #74) reviewed for accidents and falls. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #74 documented an admission date to the facility of 2/10/23. The MDS identified a Brief Interview of Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. The MDS identified the resident experienced falls prior to admission to the facility and experienced 2 or more falls without injury since admission to the facility. The MDS documented a diagnosis of Parkinson's disease. The Care Plan, with initiated date 3/2/23 documented a Focus Area of Falls as follows; the resident has had an actual fall with (no injury, minor injury, serious injury) poor balance, poor communication/comprehension, and unsteady walking. The Care Plan documented three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to assure adequate nutrition and hydration for 1 of 4 residents reviewed (Resident #75). The facility reported a census of 79 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #75 scored 0 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The resident depended on staff for transfer and required extensive assist with eating. The resident's diagnoses included aphasia (language disorder), dysphagia (difficulty swallowing), and cerbrovascular accident (stroke). The Care Plan identified the resident at risk for altered nutritional status due to dysphagia, compromised dentition, fair-poor intakes of solids (pureed food) with preferences for liquids. The resident was totally dependent on staff or family for assistance with feeding solids and liquids. The interventions included providing and serving oral nutritional supplements as ordered per 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, resident interview, and staff interview, the facility failed to provide necessary respiratory care by failing to provide portable oxygen tanks for 1 of 1 resident reviewed for respiratory care (#55). The facility reported a census of 79. Findings include: On 7/24/23 at 11:27 AM, Resident #55 stated staff told him on 6/20/23 the facility did not have portable oxygen tanks. He also stated he was confined to his room because his oxygen concentrator mobility limitations. The Electronic Health Record (EHR) listed diagnoses of Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) (lung disease making it difficult to breathe), morbid obesity, muscle weakness, and lower back pain. The Quarterly Minimum Data Set (MDS) assessment included diagnoses of CHF, COPD, and morbid obesity and indicated the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. It also revealed the resident was dependent on supplemental oxygen. The Care Plan dated 3/24/23 included the resident's dependence 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.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the facility was free of a medication error rate of 5 percent or greater. The facility's medication error rate was 10.71% which affected 2 out of 5 residents observed during the medication pass(Resident #274 and #177). The facility reported a census of 79 residents. Findings: 1. Resident #274's Minimum Data Set(MDS) assessment tool, dated 7/15/23, listed diagnoses for Resident #274 which included depression, non-Alzheimer's dementia, and respiratory failure. The MDS listed the resident's Brief Interview for Mental Status(BIMS) as 8 out of 15, indicating moderately impaired cognition. A 7/15/23 Care Plan entry stated the resident had chronic respiratory failure. A 7/24/23 Care Plan entry stated the resident received an antidepressant. On 7/26/23 at 7:50 a.m. Staff A Certified Medication Aide(CMA) prepared Resident #274's morning medications which included Resident #275's sertraline(an antidepressant) 25 milligrams(mg) half tablet(12.5 mg). Staff A also removed 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.