Atchison Senior Village Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 32 residents. The sample included 13 residents with eight residents reviewed for resident rights. Based on observation, interview, and record review, the facility failed to ensure Resident (R)7 was treated with respect and dignity during incontinence care. This deficient practice placed the resident at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R7's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), obesity (excessive body fat), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), candidiasis (a fungal infection caused by a yeast), and muscle weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R7 was dependent on staff for toileting and was frequently incontinent. R7's Care 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.

The facility identified a census of 32 residents. The sample included 13 residents with eight residents reviewed for resident rights. Based on observation, interview and record review, the facility failed to ensure Resident (R)22 was allowed to exercise her right for self-determination without intimidation. This deficient practice placed the resident at risk for negative psychosocial outcomes related to decreased autonomy and impaired rights. Findings Included: - On 04/17/24 at 11:00 AM R22 stated she felt pressured by the facility to switch pharmacy services during the facility's ownership changeover. She stated R21 (her spouse) and she were told by the facility their medications may be difficult to obtain by their previous pharmacy once the facility switched to the new one. She stated she was afraid of not receiving her medications due to her existing medical problems. R22 stated after she changed pharmacy, she had to wait two days for clotrimazole (medication used to treat a fungal infection) cream to be delivered by the new pharmacy. R22 stated she and R21 would not have changed…

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

The facility identified a census of 32 residents. The sample included 13 residents with seven reviewed for maintaining activities of daily living. Based on observation, record review, and interviews, the facility failed to assist Resident (R)16 with maintaining her amplified hearing device. This deficient practice placed R16 at risk for a decline in communication and psychosocial well-being. Findings Included: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (difficulty sleeping), and gastro-esophageal reflux disorder (GERD-backflow of stomach contents to the esophagus). R16's Annual Minimum Data Set (MDS) completed 03/04/24 noted a Brief Interview for Mental Status score of 14 indicating intact cognition. The MDS indicated she required substantial to maximal assistance for bathing, dressing, and toileting. The MDS indicated she had moderate difficulty hearing but did not use hearing aids. R16's Communication…

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

The facility reported a census of 32 residents. The sample included 13 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) care. Based on record review, interviews, and observations, the facility failed to ensure Resident (R)25's pressure-reducing device was in her recliner as care planned. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of repeated falls, muscle weakness, insomnia (difficulty sleeping), dementia (a progressive mental disorder characterized by failing memory, and confusion), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R25's Annual Minimum Data Set (MDS) completed 02/24/24 noted a Brief Interview for Mental Status score of zero indicating severe cognitive…

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 The facility identified a census of 32 residents. The sample included 13 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure the nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner to decrease exposure and contamination for Resident (R) 30. This placed R30 at increased risk for respiratory infection and complications. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a staff interview that…

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

The facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to ensure nursing staff demonstrated the appropriate competencies and skill sets to provide nursing services to care for resident's needs when staff lacked knowledge related to dosing and administering diclofenac gel (a topical ointment used to relieve arthritis pain) for Resident (R) 17. This deficient practice placed R17 at risk of adverse side effects. Findings included: - On 04/16/24 at 09:38 AM Certified Medication Aide (CMA) R prepared and dispensed medications for R17. CMA R performed hand hygiene and applied clean gloves. CMA R then opened the tube of diclofenac gel and squeezed an unmeasured amount onto her glove. CMA R did not review R17's diclofenac gel order for a dosage amount before she applied the medication. On 04/16/24 at 09:40 AM CMA R stated she was not aware that the diclofenac even had a dosage amount. CMA R stated she had always been told to just squeeze out an amount either on the finger of a glove or to squeeze some into a medication cup.…

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 The facility identified a census of 32 residents. There were 13 residents in the sample. Based on observation, record review, and interview, the facility failed to ensure Resident (R)4's medications were available for administration without missed doses during the facility's change-over to a new pharmacy provider. This deficient practice placed R4 at risk of unnecessary complications and an ineffective medication regimen. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, confusion), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical change), weakness, hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and bipolar disorder…

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 The facility had a census of 32 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the multiple unsuccessful attempts for nonpharmacological symptom management were documented including risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R) 29, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion) and received Risperdal (antipsychotic). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R29's Electronic Medical Record (EMR) documented the resident had diagnoses of subarachnoid hemorrhage (bleeding in the space just outside the brain), dementia, and hypertension (HTN-elevated…

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 The facility identified a census of 32 residents. The sample included 13 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, for Resident (R) 2 and R30. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R2 and R30. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Significant Change Minimum Data Set (MDS) dated [DATE] documented 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.

The facility had a census of 35 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care. Findings include: - Review of the July, August, and September 2022 nursing schedule revealed no Registered Nurse on the following dates: 07/01/22 through 07/07/22, 07/09/22, 07/12/22 through 07/15/22, 07/19/22 through 07/24/22, 07/26/22 through 07/29/22, 08/03/22, 08/05/22 through 08/09/22, 08/10/22 through 08/11/22, 08/14/22 08/15/22, 08/19/22 through 08/22/22, and 09/22/22. On 10/27/22 at 08:40 AM, Administrative Nurse D verified the lack of Registered Nurse coverage on the above listed dates. The facility's Nursing Service Policy, 6/ 24/22, documented a registered nurse should be on duty at least eight consecutive hours per day, seven days per week. The facility may include the director of nursing to meet this requirement. The facility failed to provide Registered Nurse…

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

The facility had a census of 35 residents. Based on interview and record review, the facility failed to provide no less than 12 hours of in-service education per year for 5 of 5 reviewed certified nurse aides. Findings included: - Review of in-services, for direct care staff N, O, P, Q, and MM, revealed the staff records completed the required 12 hours of in-service education in the prior 12 month period but no evidence of education hours were provided for the last 12 months. On 11/2/22 at 11:29AM, Administrative Nurse D verified the above findings and stated a nurse should be designated to assure certified nurse aides complete 12-hour required annual in-services and she expected competency training to be done on a yearly basis. The facility's Competency Evaluation Policy, undated, documented the facility would evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Evaluating competency of staff is accomplished through the facility's training program. Initial competency is evaluated during 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.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI), placing the 35 residents who reside in the facility at risk for lack of quality improved services. Findings included: - On 10/26/22 during entrance conference the facility failed to provide a QAPI plan. On 11/01/22 at 03:45 PM, Administrative Staff A verified the facility did not have a current QAPI plan. On 11/02/22 at 09:00AM, Administrative Staff A provided the survey team with a copy of a QAPI plan which was dated 2017 and lacked current facility information. The facility's undated Quality Assurance and Performance Improvement Plan (QAPI) policy documented the facility will design the facility's QAPI program and QAA committee responsibilities, actions and processes on how the committee will conduct activities necessary to identify and correct deficiencies. tracking and measuring performance , establish goals, develop and implement corrective actions. The QAPI…

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

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview, the facility's (QAA) Quality Assessment and Assurance program failed to indeitfy efforts to imporve multiple issues of concern. This placed the residents at risk for decreased quality of care and life. Findings included: - Based on observation, record review and interview, the facility failed to provide dignity during dining. Refer to F550. Based on observation, record review and interview, the facility failed to provide choices for bathing. Refer to F561. Based on observation, record review and interview, the facility failed to provide a safe clean environment. Refer to F584. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for elopement. Refer to F656. Based on observation, record review and interview, the facility failed to recap a discharge summary on a closed record. Refer to F661. Based on observation, record review and interview, the facility failed to provide bathing services for a 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.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QAA) that had the required QAA members and met quarterly, placing the residents at risk for lack of quality improved services. Findings included: - On 10/26/22 during entrance conference the facility did not provide a list of members of the QAA committee, and verified there has not been a QAA meeting recently. On 11/1/22 at 03:45PM, Administrative Staff A stated the facility did not currently have a QAPI (Quality Assurance Performance Improvement) plan. On 11/1/22 at 04:10PM, Administrative Nurse D verified the facility had not conducted a QAA meeting in the past five months. Review of the QA&A sign in sheets for the past year quarterly meetings were held on: 11/3/21, 02/16/22 and 05/25/22. There was no Director of Nursing or Infection Control Preventionist who attended those meetings. The required meeting should have been August 2022. The facility's undated Quality Assurance…

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 The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to have an infection control program which included tracking, education and prevention of infections. The facility further failed to ensure appropriate hand hygiene and handling of soiled linens for Resident (R) 17, who had a draining wound. This placed the residents in the facility at increased risk for infections and communicable disease. Findings included: - On 11/01/22 at 3:10PM, Administrative Nurse D verified the facility did not have a tracking or quality improvement for an infection control program. The facility's Infection Surveillance, undated policy, documented the facility will have a system of infection surveillance which serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections…

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

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 35 residents who resided in the facility at increased risk for receiving an infection and /or negative effects of antibiotic use. Findings included: - On 11/01/22 at 3:10PM, Administrative Nurse D verified the facility did not have an antibiotic stewardship program. The facility's Antibiotic Stewardship Policy, dated 05/22/22, documented the antibiotic stewardship program will be an integral part of the Infection Control Program. Antibiotics use will be tracked as part of the overall infection control monitoring system. The DON will have primary responsibility for the process along with the Pharmacy Consultant and the medical director. Monitoring will include and evaluation of antibiotic use documentation. Antibiotic prescriptions will be done monthly to assess appropriateness for the individual resident. Lab testing results will…

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

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure the facility employed a designated staff person for the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) and who completed the specialized training in infection prevention and control. Findings included: - On 10/26/22 at 08:15AM, during the initial entrance conference Administrative Staff A verified the facility did not have an Infection Preventionist. On 11/01/22 at 3:10PM, Administrative Nurse D verified the facility did not have an Infection Preventionist. The facility' Infection Preventionist undated policy, documented the facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. The facility will ensure the Infection Preventionist is qualified by education, training and certification. Develop and implement an ongoing infection prevention and control program to prevent…

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

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide a clean, sanitary and comfortable environment for residents who resided in the facility. This placed the residents at risk for impaired comfort. Findings included: - On 10/26/22 at 8:30 AM, observation revealed the following: On the 300 hall, Resident (R)17's wall next to her bed had an area with two gouges (a grove, hole or indentation in the wall). One was approximately 0.5 inches (in) wide by 12 in long. The other gouge was approximately 0.5 in wide by eight in long. The gouges had numerous areas of different size peeling paint around them. On the same hall, R38's wall beside her bed had numerous areas, varying sizes, of peeling paint. On 10/26/22 at 11:19AM, observation revealed the following: The ceiling in the dining room had two areas, approximately three feet (ft) by four ft, around two ceiling vents with black substance. The wall below the steam table was missing a piece of ceramic tile approximately six in by 12 i.…

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

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily worked shifts for Hall 300. This practice placed residents at risk for misappropriation of medications by staff and unmet therapeutic medication regimen. Findings included: -On 10/26/22 at 09:50 AM during initial tour of the facility, observation revealed the Hall 300 Narcotic Count Sheet lacked a second signature for the following second shift dates 09/09/22 through 09/12/22 and 09/20/22, 09/20/22, 09/22/22, 09/22/22 and 09/24/22 through 09/26/22. The third shift only had signatures for 10/05/22, 10/09/22, 10/15/22, and 10/24/22 (28 third shift days without signatures). On 10/26/22 at 09:50 AM Certified Medication Aide (CMA) R verified lack of signatures on the Narcotic Count Sheet' and stated the lack of signatures were probably due to agency staff. On 11/02/22 at 09:00 AM Administrative Nurse D verified the lack of signatures on the Narcotic Count Sheets 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.

The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to store food in accordance with professional standards for food service safety for the residents who received their food from the facility kitchen, when staff failed to label and date two open food items in the kitchen freezer. This placed the residents at risk for food borne illness. Findings included: - On 10/26/22 at 08:15 AM, observation revealed in the walk in freezer, located in the kitchen, had a three-quarters full bag of chocolate chip cookies and three-quarters full bag of chicken wings without a date or label. On 10/26/22 at 08:15 AM, Dietary Staff (DS) BB verified the above finding and removed and discarded the for items in the trash. DS BB stated staff should label and date food items when they open them. The facility's Food Storage Policy, revised April 1995, documented all refrigerated /frozen foods should be covered, labeled, and dated. Foods would be stored in sealed Ziploc or storage containers and labeled either with…

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

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident (R) 23, who received an insulin (a hormone to regulate glucose) injection in the dining room. This placed the resident at risk for impaired dignity Findings included: - On 10/27/22 at 07:45 AM, observation revealed R23 sat in a high backed wheelchair at a dining room table; two other residents were also seated at the table. Further observation revealed Licensed Nurse (LN) H pulled up the right sleeve of R23's shirt and administered an insulin injection in her arm. On 10/27/22 at 2:10PM, Administrative Nurse D verified R23 should not have received an insulin injection at the dining table. The Promoting Maintaining Resident Dignity, undated policy documented the facility is to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains quality of life. The facility failed 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 The facility had a census of 35 residents. The sample included 12 residents with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to ensure staff honored Resident (R) 30's personal choices for days and times of bathing per his request. This placed the resident at risk for poor hygiene and impaired autonomy. Findings included: - R30's Electronic Medical Record (EMR) documented he had diagnoses major depressive disorder (major mood disorder) and history of urinary tract infection (an infection in any part of the urinary system). R30's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R30 required limited staff assistance with dressing and personal hygiene, supervision with walk in corridor; he was independent with the rest of ADL. The MDS documented R30 required assistance with bathing. R30's ADL 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include potential risk for elopement for Resident (R) 36 and R5. Findings included: - R36's Electronic Medical Record (EMR) documented she had diagnoses of dementia (a group of thinking and social systems that interferes with daily functioning). R36's admission Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident was independently ambulatory and required no assistive devices. She wandered one to three days of the look back period. R36's Cognition Care Plan, dated 08/17/22, informed the staff the resident had confusion at times and required staff redirection. The medical record lacked an elopement assessment. The medical record lacked a care plan for elopement risk. The Social Services notes, dated…

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 The facility had a census of 35 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of the residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R) 40. This placed the resident at risk for receiving inadequate care. Findings included: - R40's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R40's admission Minimum Data Set (MDS) dated [DATE], documented R40 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R40 required limited staff assistance with dressing and toilet use and supervision with rest of activities of daily living (ADLs). The MDS documented R40 had no discharge plan. R40's Discharge Care Plan, dated 08/17/22, documented the resident planned to discharge 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 The facility had a census of 35 residents. The sample included 12 residents with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to provide bathing on a regular basis for one of four reviewed for acgtivities of daily living (ADLs), Resident (R) 30. This placed the resident at risk for poor hygiene. Findings included: - R30's Electronic Medical Record (EMR) documented he had diagnoses major depressive disorder (major mood disorder) and history of urinary tract infection (an infection in any part of the urinary system). R30's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R30 required limited staff assistance with dressing and personal hygiene, supervision with walk in corridor; he was independent with the rest of ADL. The MDS documented R30 required assistance with bathing. R30's ADL Care Plan, revised…

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 The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to assess and identify potential risk for elopement for Resident (R) 36 and R5 placing them at increased potential for injury. Findings included: - R36's Electronic Medical Record (EMR) documented she had diagnoses of dementia (a group of thinking and social systems that interferes with daily functioning). R36's admission Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident was independently ambulatory and required no assistive devices. She wandered one to three days of the look back period. R36's Cognition Care Plan, dated 08/17/22, informed the staff the resident had confusion at times and required staff redirection. The Social Services notes, dated 08/04/22 at 12:28 PM, stated R36's admitted from a home setting due to dementia and 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.