Bonner Springs Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents with five reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide four residents, Resident (R) 2, R6, R21, and R36 with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two. The admission…

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 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with resident-centered interventions to prevent pressure ulcers for one resident, Resident (R) 33. This placed the resident at risk for unmet care needs and skin breakdown. Findings included: - The Electronic Medical Record (EMR) documented R33 has diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbance of language and communication, and fragmentation of thought), dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), hypertension (high blood pressure), acquired absence of toes (a condition where one or more toes are lost as a result of trauma, infection, vascular disease, tumors or diabetes), and peripheral vascular disease (PVD - slow 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 identified a census of 34 residents. The sample included 12 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that the physician responded to the recommendations made by the Consultant Pharmacist (CP) to ensure that Resident (R) 23's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication Seroquel had an appropriate Centers for Medicare and Medicaid Services (CMS) indication for use. These deficient practices placed R23 at risk of unnecessary medication administration and related complications. Findings included: - R23's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), 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 The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for two residents, Resident (R) 8 and R21. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R8 documented diagnoses of pain, traumatic brain injury (TBI - an injury to the brain caused by external forces), dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, and hypertension (high blood pressure). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired…

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 34 residents. The sample included 12 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate diagnosis or a physician's statement of the risk versus benefit for the continued use of Seroquel (antipsychotic medication-a class of medications used to treat major mental conditions that cause a break from reality). These deficient practices placed R23 at risk of unnecessary medication administration and related complications. Findings included: - R23's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), encephalopathy (a broad term for any brain disease that alters brain function or structure), chronic obstruction…

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 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility to prevent medication administration errors for Resident (R) 8 whose heart rate was out of physician-ordered parameters and he received four blood pressure medications. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R8 documented diagnoses of pain, traumatic brain injury (TBI - an injury to the brain caused by external forces), dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, and hypertension (high blood pressure). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired…

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 34 residents. The sample included two residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R)26 and R16, which included a plan of care and a description of the services provided which included visit frequency, medications, and medical equipment. This placed the residents at risk of not receiving needed care. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), bipolar disorder (a major mental illness that causes people to have episodes of severe high and lows), depression (a mood disorder that causes a persistent feeling of sadness 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 identified a census of 31 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure there was a director of food and nutrition services employed at the facility with the required qualifications. This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 07/09/24 at 10:31 AM Social Services X worked in the kitchen. Social Services X stated the facility did not have a Certified Dietary Manager (CDM) to oversee the kitchen. Social Services X stated that she was filling in to cover the kitchen currently. She stated the facility had a full time cook, but the cook was out since 07/06/24 so she was covering for them until they returned. Social Services X stated she had a Dietary Aide to assist her in the kitchen. Social Services X stated she was unsure is the food temperature logs were done for breakfast that morning 07/09/24. Social Services X further stated Administrative Staff B helped with the kitchen as well and may have had the missing temperature logs. Social…

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 31 residents. The facility had one main kitchen. Based on observation, record review, and interview, the facility failed to ensure the facility had sufficient staff with the appropriate skill sets to carry out the functions of food and nutritional services. This deficient practice placed the resident at risk for impaired nutrition and decreased quality of life. Findings included: - Review of the facility's Resource: Refrigerator/Freezer Temperature Log for May revealed no temperatures were recorded for the morning shift for the following (21) days 05/11/24 - 05/31/24 and no recorded temperatures for evening shift for the following (6) days 05/16/24, 05/17/24, 05/23/24, 05/24/24, 05/30/24 and 05/31/24. Review of the facility's Resource: Refrigerator/Freezer Temperature Log for June revealed no temperatures were recorded for the morning shift for the following (28) days 06/03/24 - 06/30/24 and no recorded temperatures for evening shift on the following (12) days 06/06/24 - 06/11/24, 06/13/24, 06/14/24, 06/20/24, 06/21/24, 06/27/24 and 06/28/24.…

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

The facility identified a census of 35 residents. The sample include 14 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representative to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Finding Included: -On 07/31/23 at 07:05AM an inspection of the facility revealed no designated grievance box or forms available in the areas accessible to the 35 residents of the facility or their representatives. On 08/01/23 at 10:50AM, the Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported they were unaware if the facility had an official grievance process. The council reported Social Services X was responsible for complaints. The council stated if they had any concerns, they told staff and staff would relay the concerns to the administrator. On 08/02/23 at 02:30 PM Certified Nurse's Aide (CNA) M stated she was not sure if the facility had a specific…

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 14 residents with seven residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure hazardous materials in a safe, locked area, and out of reach of the seven cognitively impaired, independently mobile residents. The facility additionally failed to safely transfer Resident (R)7 utilizing the appropriate mechanical lift and staff. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 08/01/23 at 07:09AM an inspection of the facility's west hallway revealed an unsecured emergency treatment cart. The cart contained a full sealed bottle of Tylenol 325 milligram (mg) tablets (medication used for pain relief) and Geri-Dryl 25mg tablets (geriatric brand Benadryl- allergy medication) in the top drawer. The second drawer contained packaged (unused) insulin (hormone which regulates blood sugar) syringes and a small portable…

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 35 residents. Based on record review, observation, and interview, the facility failed to ensure narcotic reconciliation which included regular narcotic counts of all narcotics, including the narcotics scheduled for destruction or a system which required two qualified staff for access to a fixed and locked medication bin. This deficient practice placed the residents at risk for misappropriation and drug diversion. Findings included: - Review of the Controlled Medication Count Verification Forms dated 07/01/23 - 08/02/23, in a binder on the west hall medication cart revealed medication counts that were not signed off by a second staff member on the following days (6): 07/06/23, 07/12/23, 07/21/23, 07/25/23, 07/26/23, and 07/31/23. The following days (4) lacked a recorded entry that counts were completed by any staff member on at least one shift: 07/09/23, 07/14/23, 07/19/23, and 07/24/23. The following day (1) lacked a recorded entry that counts were completed by any staff member on both day and evening shift 07/08/23. Review of the Controlled…

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 35 residents. The sample included 14 residents with three residents identified by the facility on enhanced barrier precautions. Based on record review, observations, and interviews, the facility failed to maintain sanitary infection control practices related to laundry delivery and trash removal. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 07/31/23 at 07:04AM a walkthrough of the facility revealed three small-sized trash bags on the floor of the east hallway and two small trash bags sat on the west hallway floor filled with trash with no bin or protective barrier. On 07/31/23 at 02:12PM Housekeeping Staff V pushed a laundry cart filled with multiple resident's personal clean clothing down the west hall with no cover. On 08/01/23 at 07:21AM Maintenance Staff U stated he was not aware the laundry basket needed to be covered in transport in the facility. He stated staff should take the trash bag directly to the large trash receptacle and not place the bags directly 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.

The facility identified a census of 35 residents. The sample included 14 residents with three residents reviewed for beneficiary notices review. Based on record review and interviews, the facility failed to provide Resident (R)23 and R27 with completed Advanced Beneficiary Notice of Non-coverage (ABN Form CMS-10055). This deficient practice placed the residents at risk for impaired decisions and treatment options due to lack of information. Findings Included: - A review of R23's Beneficiary Protection Notification Review completed on 08/01/23 indicated she started Medicare Part A skilled services on 05/06/23. The form designated her last covered day (LCD) was 05/30/23. The form indicated the facility initiated her discharge from skilled with benefit days remaining. The form indicated she remained in the facility and received an ABN form. A review of R23's ABN form indicated she maxed out her physical and occupational therapy potential for skilled service. The form noted beginning on 05/30/23, R23 may have to pay out of pocket for the cost of continued services. The form 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 identified a census of 35 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to ensure staff kept Resident (R) 36, a cognitively impaired resident, free from resident to resident abuse. This deficient practice placed R36 at risk of possible harm or injury and impaired quality of life. Finding included: - The electronic medical record (EMR) for R36 documented diagnoses of psychosis (any major mental disorder characterized by a gross impairment in reality testing), Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), and Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R36 had a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. R36 exhibited behaviors of hallucinations…

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 35 residents. The sample included 14 residents with four residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R) 32. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs. Findings included: - R32's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to ensure a care plan was revised to address Resident (R) 14's skin care needs. This deficient practice placed R14 at risk for skin breakdown and possible skin infections. Findings included: - The electric medical record (EMR) for R14 documented diagnoses of hypertension (HTN- an elevated blood pressure), carcinoma of skin (a cancer that forms in tissues that line most organs and skin), nephropathy (deterioration of kidney function), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] for R14 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R14 required limited assistance of one staff member for activities of daily living (ADLs) and utilized the use of a wheelchair for mobility. R14 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The sample included 14 residents with one resident reviewed for discharge. Based on observation, record review, and interviews, the facility failed to document a discharge summary and recapitulation of the facility stay upon discharge from the facility for Resident (R) 40, which placed R40 at risk for an interruption in the continuity of care. Findings included: - R40 was admitted on [DATE] and discharged on 05/21/23. R40's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of reduced mobility, generalized muscle weakness, and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS) was not completed. R40's Care Area Assessment (CAA) was not completed. R40's Baseline Care Plan dated 05/19/23 documented R40's goal was to return to the community. Review of the EMR under Progress Notes tab revealed a Discharge Summary note dated 05/22/23 at 11:44 AM documented R40 discharged home on [DATE] per her request with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The sample included 14 residents with four resident reviewed activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was provided for Resident (R) 24, R16, and R11 who required extensive assistance with ADLs. This deficient practice placed these residents at risk for the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), and psychosis (any major mental disorder characterized by a gross impairment testing). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status…

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 35 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 33. The facility also failed to ensure weekly nurse skin assessments were completed for R14, who developed moisture associated skin damage (MASD). These deficient practices placed these residents at risk for delay in treatment related to fluid overload, skin related complications and untreated illness. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid, heart failure (severe failure of the heart to function properly), kidney failure, and fluid overload. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS…

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 35 residents. The sample included 14 residents with two residents reviewed for bowel and bladder incontinence. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 32 received treatment and services to maintain or improve his urinary continence to the highest extent possible. This deficient practice placed R32 at risk of urinary related complications, for the potential skin breakdown and/or skin complications due to poor personal hygiene, and impaired psychosocial wellbeing. Findings included: - R32's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and psychosis (any…

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 35 residents. The sample included 14 residents with one resident, Resident (R) 10, sampled for dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). Based on observation, record review and interview, the facility failed to ensure dialysis communication with the dialysis center regarding R10's health status with each procedure. This deficient practice placed R10 at risk for complications related to dialysis. Findings included: - The electronic medical record (EMR) for R10 documented diagnosis of dependence on renal dialysis, end-stage renal disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (HTN-elevated blood pressure), and neuropathy (weakness, numbness and pain from damage to the nerves usually in the hands or feet). The Annual Minimum Data Set (MDS) for R10 documented 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.

The facility identified a census of 35 residents. The sample included 14 residents with one reviewed for trauma informed care. Based on observation, record review, and interviews, the facility failed to complete screening on Resident (R)25 to provide trauma informed care. This deficient practice placed R25 at risk for decreased psycho-social wellbeing and increased behaviors. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of vascular dementia (progressive mental disorder characterized by failing memory, confusion), adjustment disorder (difficulty in managing the stressful life changes), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality). R25's Quarterly Minimum Data Set (MDS) completed 07/06/23 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. The MDS indicated no recent behaviors noted. The MDS indicated he required supervision from one staff for bed mobility, transfers, locomotion…

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 35 residents. The sample included 14 residents with one reviewed for behavior management. Based on observation, record review, and interviews, the facility failed to implement behavioral care interventions to prevent identified triggers for Resident (R)25. This deficient practice placed R25 at risk for behavioral outburst and injuries. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of vascular dementia (progressive mental disorder characterized by failing memory, confusion), adjustment disorder (difficulty in managing the stressful life changes), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality). R25's Quarterly Minimum Data Set (MDS) completed 07/06/23 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. The MDS indicated no recent behaviors noted. The MDS indicated he required supervision from one staff for bed mobility, transfers, locomotion off…

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 35 residents. The sample included 14 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to ensure the physician responded to the Consultant Pharmacist (CP) recommendation that Resident (R)10 required an appropriate indication for use, or the required physician documentation, for the antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (quetiapine). This deficient practice placed this resident at risk of unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R10 documented diagnosis of adjustment disorder with mixed anxiety and depressed mood (unwanted emotional and behavioral changes that can affect your mood, anxiety level, and ability to relate to others), dependence on renal dialysis (a type of treatment that helps your body remove extra fluid 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 The facility identified a census of 35 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to identify and notify physician of antihypertensive (treat high blood pressure) medication not administered as ordered and given for inappropriate indication for Resident (R) 32. This deficient practice placed R32 at risk for unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R32's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and psychosis (any major mental 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 identified a census of 35 residents. The sample included 14 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to ensure Resident (R)10 and R32 had an appropriate indication for use, or the required physician documentation, for the antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (quetiapine). This deficient practice placed this resident at risk of unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R10 documented diagnosis of adjustment disorder with mixed anxiety and depressed mood (unwanted emotional and behavioral changes that can affect your mood, anxiety level, and ability to relate to others), dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), end-stage…

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 14 residents. Based on observation, interview, and record review, the facility failed to discard expired insulin (hormone which regulates blood sugar) vial for Resident (R)13, albuterol sulfate (used to prevent and treat breathing difficulties) for R23, tuberculin vial (injection used in testing for tuberculosis - an illness that mainly affects the lungs) and failed to secure medications on a treatment cart. This placed the affected residents at risk for injury and ineffective medications. Findings included: - On 08/01/23 at 07:09AM an inspection of the facility's west hallway revealed an unsecured emergency treatment cart. The cart contained a full sealed bottle of Tylenol 325 milligram (mg) tablets (medication used for pain relief) and Geri-Dryl 25mg tablets (geriatric brand Benadryl- allergy medication) in the top drawer. On 08/02/23 at 12:42 PM, an observation of the east hall medication cart revealed R23's albuterol sulfate had expired on 4/23/23. On 08/02/23 at 12:55 PM, an observation of the insulin/wound care…

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 30 residents. Based on interview and record review, the facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of the residents residing in the facility. Findings included: - Review of the Daily Staff Postings revealed a lack of indication of staff call-ins, no shows, or hours actually worked by the nursing staff. Interview, on 10/27/21 at 11:53 AM, with an alert and orientated resident, revealed the staff worked hard, but it seemed like they were always short of staff. The resident further explained that the resident did not want to ask staff to assist with some personal hygiene tasks as they were so busy. Interview, on 10/27/21 at 01:58 PM, with another alert and oriented resident, revealed every shift seemed to be short of staff, and often the agency staff (staff from an outside company) did not know the needs of the residents. Interview, on 10/27/21 at 02:07 PM, with another alert and oriented resident revealed staff worked short…

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 30 residents. Based on observation, interview and record review, the facility failed to provide annual evaluations to nursing staff of the facility to assess strengths and weakness for providing resident care as required. Findings included: - Interview with Administrative Staff A, revealed the facility lacked/could not locate the nursing staff annual evaluations for the five selected Certified Nurse Aide/ Certified Medication Aide staff due for annual evaluations, as requested. The facility lacked a specific policy for annual evaluations of nursing staff. The facility failed to provide annual evaluations for the five requested nursing staff, to determine the need for education in providing resident care as required.

The facility reported a census of 30 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - During an initial tour, on 10/27/21 at 07:40 AM, and an environmental tour of the kitchen, on 10/28/21 at 11:30 AM, with dietary staff CC, the following areas of concerns were noted: 1. Two reach in refrigerators had food debris across on the bottom ledge. 2. One sauce pan had a ripped rubber handle. 3. A skilled had deep grooves into the cooking surface. 4. The ice machine had a build-up of a lyme appearance on the outside. 5. Four food turners had ripped, gouged handles. 6. Twenty spice bottles had sticky, dusty tops. 7. A six-slotted silverware holder had areas of missing protective coating. On 10/28/21 at 11:30 AM, Dietary staff CC stated, the areas of concerns needed to be corrected. Review of the Cleaning Rotation for the kitchen, dated 2016, included: Refrigerators, ice machines and food containers will be…

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 30 residents. Based on observation, interview, and record review, the facility failed to maintain a quality assurance committee that developed and implemented appropriate plans of action to correct identified infractions of resident rights, quality of care, and quality of life concerns for all residents of the facility. Findings included: - On 11/02/21 at 02:48 PM, review of the facility's Quality Assurance (QA) committee notes revealed they met at least quarterly on 02/15/21, 03/29/21, 06/24/21, 07/26/21, 08/23/21, 09/27/21, and 10/25/21, with the medical director in attendance. On 11/02/21 at 02:48 PM, Administrative Staff A stated, the facility determines which areas need to have a Performance Improvement Plan (PIP) by looking at trends in the facility, such as wounds and infections. They would also get some of the PIP ideas from concerns voiced in resident council meetings. Falls, wounds, bathing, and cleanliness were all areas which were previously discussed during QA meetings. The facility QA committee failed to maintain an adequate 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 reported a census of 30 residents. Based on interview and record review, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship by nursing staff to ensure antibiotics used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner. Findings included: - Review of the facility, Antibiotic Utilization by Resident logs revealed a compilation of antibiotics prescribed with conditions treated on a retroactive basis. Review of the Antibiotic Utilization by Resident logs dated 01/2720/21 through 02/23/2021, revealed nine residents received antibiotic therapy, whereas the color-coded facility map used to track and trend infections within the facility indicated four resident rooms with infections. Furthermore, an unsampled resident received Doxycycline (an antibiotic), 100 mg (milligram) twice a day, for 14 days, from 01/14/21 through 02/01/21 for pneumonia, and then received another round of Doxycycline, 100 mg, twice a day, for seven days for infection not…

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

The facility reported a census of 30 residents with 14 residents sampled, of whom three were reviewed for Medicare Services. Based on interview and record review, the facility failed to provide appropriate Beneficiary Protection Notification CMS (Center for Medicare/Medicaid Services) to ensure the residents' right to appeal Medicare part A services upon discontinuation for two of the three Residents (R)10 and R 11, reviewed. Findings included: - Review of Resident (R)10's medical record, provided by the facility, revealed the resident's Medicare services were to end on 05/19/21. However, the facility failed to have paperwork showing notification to the resident of the services ending. Review of R 11's medical record, provided by the facility, revealed Medicare services were to end on 09/08/21. However, the facility failed to have paperwork showing notification to the resident of the services ending. On 11/02/21 at 07:52 AM, Administrative Staff B stated, the paperwork for the liability forms were not completed by the facility for residents that received Medicare Services. 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 reported a census of 30 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility for 10 of the 20 resident rooms and one of the two shower rooms, six resident wheelchairs, and several areas in the therapy room. Findings included: - During an environmental tour on 11/02/21 at 10:19 AM, with Housekeeping/Maintenance staff U, observation revealed the following areas of concern: 1. Nine of the resident rooms had a wall heater/air conditioner unit with a build-up of dust and debris visible inside of the grates of the units. 2. One shared resident room had a trash can which was overflowing onto the floor. 3. Three resident rooms, had cabinet doors beneath the hand washing sink, with areas of chipped and missing paint. 4. Two resident rooms had loose or missing cove base. 5. Seven resident rooms had a build-up of dirt and grime around the floor's parameter of their rooms and bathrooms. 6. One resident room had an…

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 reported a census of 30 residents with 14 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for seven of the 14 residents sampled; including two Residents (R) 8 and R17, regarding falls; three residents R 10, R 19 and R 3, regarding lack of wheelchair foot pedals; one resident R 7, regarding communication with dialysis and the lack of hypertensive (HTN) medications; one resident R 28, regarding interventions to keep his groin wounds dry, and one resident R17 for safety with transfers. Findings included: - Review of Resident (R)8's electronic medical record (EMR), under the Med Diagnosis tab, revealed a diagnosis of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 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 The facility reported a census of 30 residents with 14 selected for review which included five residents reviewed for activities of daily living. Based on observation, interview and record review, the facility failed to ensure adequate personal grooming opportunities for four of the five residents including, (R)8, R25, R28, and R10. Findings included: - Review of R25's Physician Order Sheet, dated 10/2021, revealed diagnoses included glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and chronic ischemic heart disease (long term effects of decreased oxygen to the heart). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive ability and required extensive assistance 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 The facility reported a census of 30 residents with 14 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safety for the five sampled residents including; failure to provide safe transfers for two Resident R10 and R17; failed to provide safe wheelchair transports for three residents R10, R19, and R3; and failed to initiate appropriate interventions following falls for two residents R8 and R17. Findings included: - Review of Resident (R)8's electronic medical record (EMR), under the Med Diagnosis tab, revealed a diagnosis of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The resident required limited assistance of one staff…

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 reported a census of 30 residents. Based on observation, interview, and record review, the facility lacked a system to minimize potential loss or diversion of the resident's discontinued medications. Findings included: - On [DATE] at 03:28 PM, observation of the medication room noted the following concerns: There were three boxes of various discontinued medications for multiple residents, with no type of a tracking system. The medications included, but were not limited to the following: 1. Sixty-eight Seroquel (an antipsychotic) tabs, 25 milligrams (mg) each. 2. Thirty-four Seroquel tabs, 50 mg each. 3. Twenty-two Altace (anti-hypertensive) tabs, 10 mg each. 4. Thirty-three Zoloft (antidepressant) tabs, 50 mg each. 5. Thirty Zyprexa (antipsychotic) tabs, 5 mg each. 6. Six unopened bottles of Lantus (insulin). 7. Three unopened tubes of Lidocaine Cream. 8. One unopened Combivent inhaler (respiratory medication). 9. Two unopened Albuterol inhaler (respiratory medication). 10. One unopened Spiriva…

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 30 residents. Based on observation, interview, and record review, the facility failed to provide adequate housekeeping services to maintain a sanitary clean floor in the facility kitchen. Findings included: - During an environmental tour of the kitchen on 10/28/21 at 11:30 AM, observation revealed the floor of the kitchen had a build-up of dirt and grime around the perimeter of the entire room, including underneath the shelves and storage racks. On 10/28/21 at 11:30 AM, Dietary staff DD stated, the kitchen floor needed to be cleaned. The facility policy for Cleaning Rotation, dated 2016, included: The kitchen floor will be cleaned daily. The facility failed to provide adequate housekeeping services to maintain a clean floor in the facility kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 30 residents with 14 selected for review, which included one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure one resident (R)17 was dressed in a dignified manner on two occasions. Finding included: - Review of resident (R) 17's Physician Order Sheet, dated 10/2021, revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), polyosteoarthritis (degenerative changes to one or many joints characterized by swelling and pain in multiple joints) and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognitive status, required extensive assistance of one staff for dressing. The Activities Care Area Assessment (CAA), dated 09/21/21, assessed the resident required extensive assistance with activities of daily living. The Care Plan, initiated 09/10/21, instructed staff the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 30 residents with 14 residents sampled, including one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide the one Resident (R)10 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital. Findings included: - The Physician Order Sheet (POS), dated 10/04/21, documented the resident had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the resident's electronic medical record (EMR), under the Progress Note tab, revealed the resident admitted to the hospital on [DATE], for a diagnosis of altered mental status…

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 reported a census of 30 residents with 14 selected for review. Based on observation, interview and record review, the facility failed to complete a baseline care plan for one resident (R)17 as required. Findings included: - Review of resident (R) 17's Physician Order Sheet, dated 10/2021, revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), polyosteoarthritis (degenerative changes to one or many joints characterized by swelling and pain in multiple joints) and major depressive disorder (major mood disorder.) The resident admitted to the facility on [DATE]. The resident's medical record lacked a Base Line Care Plan. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognitive status, and required extensive assistance of one staff for transfers, bed mobility, and toileting. The resident had a fall prior to admission, and a noninjury fall since admission. The Activities Care Area Assessment (CAA), 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 reported a census of 30 residents with 14 selected for review which included 1 resident reviewed for discharge. Based on interview and record review, the facility failed to complete a discharge summary for one resident (R)34, who discharged to home. Findings included: - Review of resident (R)34's Physician Order Sheet, dated 06/28/21, revealed diagnoses included chronic kidney disease, hypertension (elevated blood pressure), diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and post-surgical aftercare. The electronic medical record Census tab revealed the resident admitted initially to the facility on [DATE] and discharged from the facility 08/14/21. A Nursing Progress Note, dated 08/14/21, documented the resident discharged to home with home health care on 08/14/21, with all medications, narcotics and instructions given to the resident. Interview, on 11/02/21 at 10:30 AM, with Social Service Staff X, confirmed the discharge summary 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 40 residents with 14 selected for review, which included one resident reviewed for activities. Based on observation, interview and record review, the facility failed to provide person centered activities for one resident (R)17. Findings included: - Review of resident (R) 17's Physician Order Sheet, dated 10/2021, revealed diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), polyosteoarthritis (degenerative changes to one or many joints characterized by swelling and pain in multiple joints) and major depressive disorder (major mood disorder.) The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognitive status, required extensive assistance of one staff for transfers and bed mobility. The resident had a fall prior to admission, and a noninjury fall since admission. Facility staff completed the resident preferences as interest in reading books, newspapers, magazines, listening to music, being…

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 reported a census of 30 residents with 14 selected for review, which included four residents reviewed for skin issues. Based on observation, interview and record review, the facility failed to provide wound care in a sanitary manner for two residents (R)4 and R28 to promote healing and failed to monitor and treat multiple abrasions on R10's lower extremities to promote healing. Findings included: - Review of R4's Physician Order Sheet, dated 10/2021, revealed diagnoses included lymphedema (swelling caused by accumulation of lymph), chronic venous hypertension (elevated pressure of the flow of blood) with inflammation of the bilateral lower extremities and Schizoaffective disorder, bipolar type, (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin.) The Quarterly Minimum Data Set (MDS), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 30 residents with 14 residents sampled, including one resident reviewed for dialysis. Based on observation, interview, and record review, the facility failed to ensure appropriate adequate communication between the dialysis center and the facility, for the one Resident (R)7, regarding a lack of regular dialysis communication sheets, with the facility. Findings included: - The Physician Order Sheet (POS), dated 10/04/21, for Resident (R)7, documented diagnoses which included: type I diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and end stage renal disease (a terminal disease because of irreversible damage to vital tissues or organs). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received dialysis while a resident in the facility. The Activities of Daily Living (ADL)…

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 reported a census of 30 residents with 14 selected for review which included five residents selected for review for unnecessary medications . Based on observation, interview and record review, the facility failed to act upon the pharmacist recommendations for two of the five residents reviewed, including Resident (R)4 for topical Diclofenac (an anti-inflammatory medication) gel dose and R7 for as needed Clonidine (an antihypertensive) administration. Findings included: - Review of resident (R)4's Physician Order Sheet, dated 10/2021, revealed diagnoses included lymphedema (swelling caused by accumulation of lymph), chronic venous hypertension (elevated pressure of the flow of blood) with inflammation of the bilateral lower extremities and schizoaffective disorder, (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond 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 Physician Order Sheet (POS), dated 10/04/21, for Resident (R)7, documented a diagnosis of hypertension (HTN-elevated blood pressure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The care plan for HTN, dated 08/28/21, instructed staff to give the resident his medications, as ordered and to monitor for side effects of the medication. Review of the resident's electronic medical record (EMR), under the Orders tab, revealed a physician order for Clonidine (a hypertensive medication) 0.1 milligrams (mg), by mouth (po), every 4 hours, as needed (PRN) for systolic blood pressure (SBP-top number) greater than 180 or diastolic blood pressure (DBP-bottom number) greater than 100, ordered 04/02/21. Review of the resident's EMR under the Vital Signs tab, from 10/01/21 through 10/31/21, revealed the following BP's which were out of parameter: On 10/01/21, the resident's blood pressure (BP) was 188/92. 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.