Diversicare Of Chanute

The facility reported a census of 49 residents with five residents selected for review, including one reviewed for medication errors. Based on interview and record review, the facility failed to start a physician ordered medication for Resident (R)1, that resulted in 22 days without the ordered medication. Findings included: - The Medical Diagnosis tab in Resident (R)1's electronic medical record (EMR) included diagnoses of atrial fibrillation (rapid, irregular heartbeat) and dependence on renal (kidney) dialysis (procedure where impurities or wastes were removed from the blood). The Quarterly Minimum Data Set dated 03/07/24 revealed R1 did not take an anticoagulant medication (medication used to thin the blood to prevent clot formation). The Cardio-Kidney Vascular Care Ellipsys [minimally invasive procedure creating a fistula for dialysis] Discharge Instructions dated 02/22/24, revealed R1 was to take regular medicine including the blood thinner. The instructions included the Procedure Room - Medication Reconciliation form which included an order for apixaban (Eliquis -…

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 50 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for three of the three Certified Nurse Aides (CNA) reviewed, CNA M, CNA N and CNA O and failed to complete an annual performance review at least once every 12 months for two of the Certified Medication Aides (CMA) reviewed, CMA R and CMA S. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concern: Review of Certified Nurse Aide (CNA) M, hired 07/2019, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) N, hired 07/2022, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) O, hired 02/2023, lacked an annual performance review in her personnel file. Review of Certified Medication Aide (CMA) R, hired 01/2022, lacked an annual performance review in her personnel file. Review of Certified Medication Aide (CMA) S, hired 06/2022, lacked 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.

The facility reported a census of 50 residents. Based on observation and interview, the facility failed to maintain a two-inch air gap between the ice machine drainpipe and drain in the kitchen to prevent back up of contaminated water into the ice machine. Findings included: - Observation, on 02/28/24 at 09:37 AM, revealed the water drain in the kitchen was full of water with the drainpipe from the ice machine positioned directly in the water. Interview, on 02/28/24 at 09:57 AM with Maintenance Staff U, confirmed the lack of an air gap and the ice machine drainpipe positioned in the backed-up kitchen drainage plumbing. Staff turned the ice machine off on 02/27/24 at approximately 08:30 PM. The facility lacked a policy for maintaining a two-inch air gap between the ice machine drain and the kitchen drain. The facility failed to ensure a two-inch air gap between the ice machine drain and the kitchen drain to prevent contamination and food borne illness amongst the residents.

The facility reported a census of 50 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to weekend staffing, when the facility failed to accurately report weekend staffing during the third and fourth quarter of 2023. Findings Included: - Review of the 'Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY) Quarter 3, 2023 (April 1-June 30) and Quarter 4 (July-September), 2023 revealed extremely low weekend staffing. Review of the Staffing Sheets from April 2023 through September 2023, revealed equal staffing on the weekends as during the week. Interview, on 03/04/24 at 08:22 AM, with Administrative Nurse D, revealed the facility's corporate office compiles the staff hours for the PBJ and transmits the data to CMS. Administrative Nurse D confirmed 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 50 residents. Based on observation and interview, the facility failed to ensure to maintain the environment in a safe, sanitary, and homelike manner to promote the well-being of the residents. Findings included: - Observation, on 02/27/24 at 08:30 AM, revealed the following areas of concern: 1. The beauty shop contained a floor mat which was torn across the entire surface. The floor in the beauty shop contained four stained tiles around the base of the heating/air conditioning unit. The vent on the ceiling contained an accumulation of dust. 2. The shower room on east hall contained 15 two by two tiles that were missing/loose around the drain. 3. Three resident rooms contained an unoccupied, unmade sanitized bed. 4. A resident room contained an unused commode bucket under the bed. 5. Three resident room hall doors contained broken/buckled plastic door guards. 6. Two resident rooms contained torn door molding. 7. One resident room contained wooden cupboards with scratches horizontally across the surface and the drawers to the wooden unit contained…

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 50 residents with 17 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for four of the residents sampled, including Resident (R)28 and R43, regarding fall interventions, and R 9 and R 19 regarding specific, individualized parameters for hypertensive medications (medications used to lower blood pressure-BP). Findings included: - Review of Resident (R)28's electronic medical record (EMR) included a diagnosis of weakness. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She required substantial/maximal assistance of staff for toileting and was independent with supervision or touch assistance for sitting to standing, transferring from her bed to a chair or from her chair to a bed and transferring to the toilet. She used a walker and a wheelchair and had no falls…

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 50 residents with 17 residents selected for review, which included three residents reviewed for positioning/mobility. Based on observation, interview, and record review, the facility failed to ensure restorative services for one Resident (R)33, of the three residents reviewed for positioning/mobility. Findings included: - Review of Resident (R)33's Physician Order Sheet, dated 02/05/24, revealed diagnoses that included hemiplegia/paresis (paralysis/weakness on one side of the body), due to cerebral vascular accident (CVA or stroke which is the 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), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and diabetes (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], assessed the resident with a Brief…

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 50 residents with 17 residents included in the sample, including two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to initiate appropriate interventions following non-injury falls for two Residents (R)28 and R 43. Findings included: - Review of Resident (R)28's electronic medical record (EMR) included a diagnosis of weakness. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She required substantial/maximal assistance of staff for toileting and was independent with supervision or touch assistance for sitting to standing, transferring from her bed to a chair or from her chair to a bed and transferring to the toilet. She used a walker and a wheelchair and had no falls since admission to the facility. The Falls Care Area Assessment (CAA), dated 12/19/23, documented the was at risk for falls. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 50 residents with 17 residents selected for review, which included one resident reviewed for dialysis services. Based on observation, interview, and record review, the facility failed to ensure staff assessed one Resident (R) 13, post hemodialysis (a procedure where impurities or wastes were removed from the blood). Findings included: - Review of Resident (R) 13's Physician Order Sheet, dated 02/26/24, revealed diagnoses included chronic kidney disease with dialysis, heart failure, and femur (thigh bone) fracture. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident received dialysis treatments. The Nutrition Care Area Assessment (CAA), dated 11/21/23, assessed the resident at risk for weight instability, impaired fluid balance and abnormal lab values. The Care Plan reviewed 02/05/24, instructed staff the resident received hemodialysis three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 50 residents with 17 residents sampled, including one resident reviewed for insulin use. Based on interview, record review, and observation, the facility failed to follow physician's orders for one sampled Resident (R)11, regarding notification to the physician of blood sugars (BS) outside of parameters, as ordered. Findings included: - Review of Resident (R)11's electronic medical record (EMR) revealed a diagnosis of type II diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She received insulin seven of the seven days of the assessment period. The Nutritional Status Care Area Assessment (CAA), dated 01/20/24, documented the resident had a high body mass index (BMI), weight instability and impaired fluid balance. The care plan for alteration…

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 50 residents with 17 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure two Resident (R) 9 and R 19 remained free from unnecessary medications related to failure to hold hypertensive medications (medications used to lower blood pressure). Findings included: - Review of Resident (R)9's Physician Order Sheet (POS), dated 12/27/23, documented the resident had 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 10, indicating moderately impaired cognition. The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/23/23, documented the resident had anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Mood State CAA, dated 05/23/23, documented the resident had a diagnosis of schizophrenia (mental…

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 54 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: - Interview with eight alert residents revealed the following concerns: Interview, on 05/22/22 at 10:47 AM , with resident (R)7 revealed there have been times when there was a lot of agency staff that do not know the residents or what medications he was on. Interview, on 05/22/22 at 11:24 AM, with R15 revealed there were times on the evening/night shift when only one nurse was on duty for the entire building and she received her evening insulin late and one time at midnight. Interview, on 05/22/22 at 01:08 PM, with R10 revealed that at night there was one nurse in the entire building (54 residents) and this made her feel at risk if she should need a nurse in case of an emergency. Interview, on 05/22/22 at 12:05 PM, with R19, revealed there was not enough staff 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 reported a census of 54 residents. Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner, for the residents of the facility. Findings included: - Observation on 05/24/22 at 01:49 PM, the environmental tour of the kitchen revealed clean ready for use pot lids, steam table food pans, cutting boards and baking sheets sat stored on a lower shelf below the sink drain. The dry storage area contained opened and unsecured 50-pound bags of flour and bread crumbs. The ice machine contained two drainage pipes that lacked a two-inch air gap from the top of the floor drain to prevent backflow contamination of drainage water up into the resident's ice. On 05/24/22 at 02:15 PM, Dietary Staff BB, confirmed the above areas of identified concerns in need of maintenance and/or housekeeping. The facility policy for, Warewashing, revised 09/2017, instructed staff all dishware will be air dried and properly stored. The facility policy for, Food Storage: Dry Goods, instructed staff all packaged and canned food items will be kept clean,…

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 54 residents with 17 residents sampled. Based on interview, record review, and observation, the facility failed to provide proper infection control practices for three residents, including: (R)4 and R47, regarding unsanitary pressure ulcer/wound dressing changes and R 8, regarding urinary catheter tubing directly on the floor. Findings included: - During an observation of a pressure ulcer (PU) dressing change for Resident (R)4, on 05/23/22, the Licensed Nurse (LN) I entered the resident's room to change the dressing to the resident's right heel. LN I put on new gloves, cleansed the area with normal saline (NS) and patted dry with a 2 X 2 in (inch) gauze pad. Skin prep (used to protect the skin around a wound) was applied around the area and a new dressing was applied. LN I failed to change gloves between cleansing the wound and applying a new dressing to the unstageable PU, with signs of infection. On 05/23/22 at 10:11 AM, LN I stated she had not changed gloves after cleansing…

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 54 residents and identified 11 as unvaccinated. Based on interview and record review, the facility failed to ensure staff provided COVID-19 vaccination information/education which included benefit verses risk to ensure informed consent/declination for six of the 11 residents identified, including Resident (R)28, R7, R12, R35, R50 and R101 as required. Findings included: - Review of the COVID -19 declination revealed it lacked indication of what education facility staff provided or if the education included a benefit verses risk statement to make an informed decision. Furthermore, four of the six declinations were signed two to six months after their admissions. Review of declination forms revealed the following areas of concern: R 28 admitted on [DATE], with the declination signed on 05/25/22, 2 months later. R50 admitted on [DATE], with the declination signed on 05/24/22, 22 days later. R 7 admitted on [DATE], with the declination signed on 05/24/22, 6 months later. R12…

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 54 residents. The facility had one kitchen with one stove that two ovens for staff to cook meals for the residents of the facility. Based on observation and interview the facility failed to ensure the two ovens were in adequate safe working condition, for the residents of the facility. Findings included: - Interview, on 05/24/22 at 11:30 AM, with Dietary Staff CC, revealed the ovens did not hold a consistent temperature. Staff turned the ovens up to the highest temperature of 500 degrees, but the staff were unsure of the actual exact temperature the ovens maintained, and staff guessed at the cooking time for the food items cooked in these ovens. Observation, on 05/24/22 at 11:45 PM, revealed Maintenance Staff U obtained temperatures of the ovens (set at 500 degrees Fahrenheit) using a laser type of thermometer. The right-side oven registered a temperature of approximately 402 degrees Fahrenheit, and the left side oven varied between 388 to 410 degrees Fahrenheit. Interview, on 05/24/22 at 12:20 PM, with Dietary Staff BB, confirmed the ovens did not…

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

The facility reported a census of 54 residents with four reviewed for insulin administration. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure nursing, administration of insulin, and related to attain or maintain the highest physical, mental and psychosocial well-being of the residents residing the in the facility. Findings included: Review of the Staff Daily Posting reviewed on licensed nurse on night shift, (06:00 - 06:00 AM) on the following days; -03/24/22, 03/25/22, 03/28/22, 03/29/22, 03/30/22 and 03/21/22. -04/01/22, 04/03/22, 04/04/22, 04/05/22, 04/06/22, 04/07/22, 04/08/22, 04/09/22, 04/11/22, 04/12/22, 04/13/22, 04/14/11, 04/15/22, 04/16/22, 04/18/22, 04/19/22, 04/20/22, 04/24/22, 04/25/22, 04/26/22, 04/27/22, 04/28/22, 04/29/22 & 04/30/22. -05/01/22, 05/02/22, 05/03/22, 05/04/22, 05/05/22, 05/06/22, 05/08/22, 05/09/22, 05/10/22, 05/11/22, 05/12/22, 05/13/22, 05/18/22, 05/19/22, 05/20/22, 05/21/22, and 05/22/22. - On 05/24/22 at 08:44 AM, Certified Medication Aide (CMA) T reported when the monthly schedule…

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 54 residents with 17 selected for review which included five residents selected for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure administration of medications as ordered for three of the five selected residents including: residents (R)29 when the staff failed to administer the potassium supplement (a medication to provide a balance of electrolytes when taking medication to remove excess fluid from the body) and two residents (R) 15 and R37, when staff failed to administer 08:00 PM doses of insulin (a medication to control blood sugar) within the timeframe, as ordered by the physician. Findings included: - Review of resident (R)29's Physician Order Sheet, dated 05/01/22, revealed diagnoses included heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), chronic pain, and chronic atrial fibrillation (rapid, irregular heartbeat). The 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 reported a census of 54 residents. Based on observation, interview and record review, the facility failed to provide palatable (pleasant to taste) meals for at least six interviewable residents (R) 15, 21, 153, 7, 32 and 47. Findings included: - Interviews with the following six alert residents, revealed the following complaints/concerns with the food served from the facility kitchen: On 05/22/22 at 10:48 AM, R7 reported the staff often served foods cold. An example reported was that most recently the kitchen served uncooked French fries. On 05/22/22 at 11:08 AM, R47 stated the French fries served one evening were not done and served cold. On 05/22/22 at 11:21 AM, R15 reported the kitchen served repetition of the same foods, week after week, with fish twice a week. The resident provided an example as the French fries and tator tots not being thoroughly cooked and served cold. On 05/22/22 at 11:47 AM, R21 explained that the foods were served not thoroughly cooked and the residents were not offered…

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 54 residents with 17 selected for review which included two residents reviewed for other skin conditions. Based on observation, interview and record review, the facility failed to provide sanitary dressing change for one of the two sample residents (R)47, to promote healing and prevent infection. Findings included: - Review of resident (R)47's Physician Order Sheet, dated 04/28/22 revealed a surgical amputation of the right index finger, osteomyelitis (local or generalized infection of the bone and bone marrow) of the right hand diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, and required extensive assistance of one staff for bed mobility, transfer and dressing, and staff supervision for eating. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 54 residents with 17 residents sampled, including five residents reviewed for accidents. Based on interview, record review and observation, the facility failed to initiate appropriate interventions to keep one Resident (R)153 from falls, and failed to ensure one bariatric shower chair was in safe condition for residents who used it, on one of two halls of the facility. Findings included: - Review of Resident (R)153's electronic medical record (EMR), under the Med Diag tab, included a diagnosis of morbid obesity (a serious health condition that can interfere with basic physical functions such as breathing or walking). The significant change Minimum Data Set (MDS), dated [DATE], lacked documentation of the resident's cognition. She required extensive assistance of two staff for bed mobility and transfers. Her balance was not steady and she had no impairment in functional range of motion (ROM). She had no falls since the prior assessment. The falls 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 54 residents with 17 residents sampled, including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview and record review, the facility failed to appropriately handle the urinary catheter bag during cares for one of the two samples, Resident (R)8, in a manner to prevent urinary tract infections. Findings included: - Review of Resident (R)8's electronic medical record (EMR) under the Med Diag tab, included a diagnosis for retention of urine (lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He required extensive assistance of two staff for transfers and required extensive assistance of one staff for toileting. He had an indwelling urinary catheter (insertion of a catheter into the bladder to drain…

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 54 residents with 17 selected for review which included one resident reviewed for dialysis services. Based on observation, interview and record review, the facility failed to ensure follow-up on communications from the dialysis center for the one sampled resident(R)47. Findings included: - Review of resident (R)47's Physician Order Sheet, dated 04/28/22 revealed a surgical amputation of the right index finger, osteomyelitis (local or generalized infection of the bone and bone marrow) of the right hand, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident required extensive assistance of one staff for bed mobility, transfer and dressing, and staff supervision for eating. The resident had no…

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 54 residents with five selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure one of the five residents (R)29, medications were ordered and followed up on in a timely manner. Findings included: - Review of resident (R)29's Physician Order Sheet, dated 05/01/22, revealed diagnoses included heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), chronic pain, and chronic atrial fibrillation (rapid, irregular heartbeat). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment and on schedule pain medication. The pain interview revealed no pain present. The resident received seven days of antipsychotics, five days of antidepressants, six days of anticoagulants, five days of diuretic (medication to remove excess fluid from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 54 residents with 17 selected for review which included two residents reviewed for nutritional services. Based on observation, interview and record review, the facility failed to provide a physician ordered therapeutic renal diet for one of the two sampled residents, (R)47. Findings included: - Review of resident (R)47's Physician Order Sheet, dated 04/28/22, revealed a surgical amputation of the right index finger, osteomyelitis (local or generalized infection of the bone and bone marrow) of the right hand diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, and he required extensive assistance of one staff for bed mobility, transfer and dressing, and staff supervision for eating. The resident had no…

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.