Kaw River Care And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to assess or provide a restorative range of motion for Resident (R) 16. This deficient practice placed the resident at risk for discomfort, stiffness, and the possibility of forming contracture (abnormal permanent fixation of a joint or muscle). Findings included: - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of seizure (violent involuntary series of contractions of a group of muscles), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - 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) effecting left nondominant side, attention and concentration deficit, hypertension (high blood pressure), metabolic…

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 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure that the daily posted nurse staffing data included the facility census. Findings included: - On 05/06/25 at 01:20 PM, the daily posted staffing sheets were requested for the past 18 months. The daily posted staffing sheets reviewed from 01/01/24 to 03/31/25 lacked the daily facility census number. On 05/07/25 at 11:00 AM, Administrative Nurse D stated the staffing coordinator was responsible for ensuring that the daily posted staffing sheet was posted. Administrative Nurse D stated that he had been made aware recently that the daily posted staffing sheets had not included the census number and has since corrected the issue. The facility's Posting Direct Care Daily Staffing Numbers dated 10/24 documented the facility would post on a daily basis for each shift, the number of personnel responsible for providing direct care to residents.

The facility identified a census of 37 residents. The sample included 12 residents, who were reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider. This deficient practice created a risk for missed or delayed services and impaired care for Resident (R) 30 and R25. Findings Included: - R30's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA - 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), respiratory failure with hypoxia (occurs when the lungs cannot adequately transfer oxygen into the blood, leading to a low level of oxygen in the blood and tissues), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), pain, unsteadiness on feet, lack of coordination, weakness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 32 residents. The sample included six residents. Based on record review, observations, and interviews the facility failed to provide care and services that promoted resident dignity for Resident (R) 1. This placed R1 and other residents in the vicinity at risk for impaired dignity and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with a diagnosis of encephalopathy (diseases of the brain that cause altered mental state and confusion). The EMR recorded R1 had diagnoses of cognitive communication deficit, (problems with communication that have an underlying cause in cognitive deficit rather than a primary language or speech deficit), amnesia, (a partial or total loss of memory), and acute kidney failure (a loss of kidney function caused by illness, infections, or injury). The Quarterly Minimum Data Set (MDS), dated 09/20/24, documented R1 had a Brief Interview for Mental Status score of 11…

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 33 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure that there was a registered nurse (RN) on staff for at least eight consecutive hours, seven days a week. This deficiency had the potential for poor quality of care and negative outcomes for the residents. Findings included: - Review of the facility daily staffing sheets and actual working schedule from 04/01/22 to 12/31/22 and 04/01/23 to 08/24/23 revealed the facility did not provide proof of having eight consecutive hours of RN coverage on 48 days during that period. The facility failed to provide proof of eight consecutive RN hours on the following weekend dates from 04/01/22 to 06/30/22: (04/24/22, 05/01/22, 05/07/23, 05/21/22, 05/22/22, 06/05/22, 06/25, and 06/26/22). The facility failed to provide proof of eight consecutive RN hours on the following weekend dates from 07/01/22 to 09/30/22: (07/09/22, 07/10/22, 07/16/22/22, 07/30/22, 08/13/22, 08/14/22, 08/27/22, 09/05/22, 09/24/22, and 09/25/22). The facility…

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

The facility identified a census of 32 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings included: - On 08/22/23 at 07:21 AM an observation in the kitchen's dry food storage area revealed one opened bag of wheat bread. The bag was undated. On 08/22/23 at 07:22 AM an observation in the kitchen's dry food storage area revealed one opened bag of hamburger buns. The bag had a large hole torn in it exposing the hamburger buns to air and the bag was undated. On 08/22/23 at 07:23 AM an observation in the kitchen's dry food storage area revealed one opened bag of hotdog buns. The bag had a large hole torn in it exposing the hotdog buns to air and the bag was undated. On 08/22/23 at 07:24 AM an observation in the kitchen's dry food storage area revealed one opened bag of tortilla chips. The bag was undated. On 08/22/23 at 07:33 AM 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 identified a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to consistently provide facility directed weekend activities to the cognitively impaired residents unable to self direct. This deficient practice had the risk for a decline in psychosocial well-being. Findings included: - The facility had nine residents that had a Brief Interview for Mental Status (BIMS) score of eight or less (indicating severely impaired cognition). Review of the monthly activity calendar for June 2023 revealed weekend activity on Saturday and Sunday of: Resident Choice Movie and Music. On Sunday 06/04/23 and 06/18/23 included the 06:00 PM Church service. Review of the monthly activity calendar for July 2023 revealed weekend activity on Saturday and Sunday of: Resident Choice Movie and Music. On Sunday 07/02/23 and 07/16/23 activities included the 06:30 PM Church service. Review of the monthly activity calendar for August 2023 revealed weekend activity on Saturday and Sunday of: Resident Choice Movie and…

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

The facility had a census of 33 residents. The sample included 12 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. This deficient practice placed the 12 residents at risk for preventable injuries and accidents. Findings Included: - On 08/22/23 at 07:04AM an initial walkthrough of the facility was completed. An inspection of the supplemental oxygen storage room revealed no lock or mechanism to secure the room's contents from opening the door. The room contained 20 full cylindrical oxygen cannisters stored in the rack with the room. Licensed Nurse (LN) G stated the door should be locked but she was not sure if it could be. LN G stated she would notify Administrative Nurse D. The lockable doorknob was placed at 09:00AM. An inspection the East Hall revealed an unsecured utility closet with an open and unlocked electrical switch panel. The panel contained the label warning…

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 33 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to ensure there was a sufficient number of nursing staff to provide care and to respond to each resident's basic needs and individual needs. This deficient practice had the potential for physical or psychosocial harm. Findings included: - The Payroll Based Journal (PBJ) report provided by the Centers for Medicare and Medicaid Services (CMS) for FY 2023 Quarter one documented the facility had one star staffing. The facility had posted scheduled smoking times for residents at 09:30 AM, 01:30 PM, 05:30 PM, and 07:30 PM. On 08/22/23 at 10:11 AM R 24 stated that staff were slow when offering smoke breaks and she always had to wait on a staff member to be available to take residents out to smoke. On 08/23/23 at 01:04 PM R24 voiced during an interview with Resident Council members that the facility a lot of times did not have an aide assigned for the scheduled smoking times so the residents would often have to wait for a staff member…

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 33 residents. The sample included 12 residents. Based on record review, observations, and interviews, the facility failed to maintain sanitary infection control practices related to indwelling catheters (tube inserted into the bladder to drain urine into a collection bag), wound care, laundry services, and medication administration. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 08/22/23 at 07:05AM an inspection of the Main Hall revealed the soiled utility room was unsecured. On 08/22/23 at 07:10AM an inspection of the unsecured West Hall shower room revealed an overfilled trashcan next to the toilet with soiled incontinence products. On 08/22/23 at 07:59AM observation revealed soiled linen on the floor of Resident (R)6's room. On 08/22/23 at 09:18AM staff transported a clean linen cart down the East Hall without a cover or protective barrier. The cart contained clean bed linen. Housekeeping Staff U stated the soiled linen room usually was locked and laundry should…

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 33 residents. The sample included 12 residents. Based on observation, record review, and interviews the facility failed to provide care in a respectful, dignified manner for Resident (R) 6 when staff failed to close the door to his room, to ensure privacy, while staff assisted him in changing his clothes and for R25, when staff performed personal cares without ensuring total privacy. This placed the residents at risk for impaired dignity and quality of life. Findings included: - On 08/22/23 at 07:10 AM Certified Nurse Aide (CNA) O was witnessed from the hallway as he assisted R6 with a clothing change. R6's bedroom door was open, and the privacy curtain was not pulled. CNA O was also heard from the hallway as he told R6 to take off his shirt and pants and then instructed R6 to put on clean ones. On 08/24/23 at 01:56 PM CNA M stated when staff were assisting residents with a clothing change in their rooms, the door should be closed and if the resident had a roommate, the privacy curtain should be pulled. On 08/24/23 at 03:18 PM Administrative Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 33 residents. The sample included 12 residents with one resident 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)180. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs. Findings included: - R180's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), left-sided hemiplegia (paralysis of one side of the body), and vascular dementia (progressive mental disorder characterized by failing memory, confusion). R180's EMR recorded a Discharge Assessment-Return Anticipated Minimum Data Set (MDS) which recorded R180 discharged to the acute hospital on [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 identified a census of 33 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, interview and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)180 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. This placed the resident at risk for impaired rights Findings included: - R180's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), left-sided hemiplegia (paralysis of one side of the body), and vascular dementia (progressive mental disorder characterized by failing memory, confusion). R180's EMR recorded a Discharge Assessment-Return Anticipated Minimum Data Set…

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 33 residents. The sample included 12 residents with one resident reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension)/mobility). Based on observation, record review, and interviews, the facility failed to create a comprehensive care plan to address restorative services for Resident (R) 9, which placed him at risk of loss of ability to perform activities of daily living (ADLs) and development of contractures (abnormal fixation of a joint or muscle) due to uncommunicated care needs. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by…

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 33 residents. The sample included 12 residents with two reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) care. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate application of Resident (R)25 pressure relieving boots, failed to ensure repositioning which included ensuring feet were not pressed into the footboard, and failed to provide wound care per standards of practice. This deficient practice placed R25 at risk for complication related to skin breakdown and pressure ulcers. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute kidney failure, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), dysphagia (swallowing difficulty), and atherosclerotic heart disease (hardening of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension)/mobility. Based on observation, record review, and interviews, the facility failed to provide services to prevent a potential decrease in ROM/mobility and/or worsening of contractures (abnormal fixation of a joint or muscle) for Resident (R) 9, which placed him at risk of loss of ability to perform activities of daily living (ADLs) and development of contractures. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by…

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 33 residents. The sample included 12 residents with three reviewed for incontinence care. Based on observations, record reviews, and interviews, the facility failed to provide appropriate indwelling urinary catheter (tube inserted into the bladder to drain urine into a collection bag) care and placement per standards of practice for Resident (R)25. This deficient practice placed R25 at risk for complication related complications. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute kidney failure, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), dysphagia (swallowing difficulty), and atherosclerotic heart disease (hardening of the blood vessel within the heart). R25's Quarterly Minimum Data Set (MDS) completed 07/01/23 noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS indicated he required extensive…

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 33 residents. The sample included 12 residents with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review, the facility failed to assess and document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for infection or bleeding every day and failed to obtain communication from the dialysis center and assess post dialysis for Resident (R) 81. This deficient practice placed R81 at risk for complications related to dialysis. Findings included: - R81's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic kidney disease (CKD - damaged kidneys and unable to filter blood the way they should), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS) was in progress for R81. R81's Care Area Assessment (CAA) was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 33 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding lack of dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 80, no duration for as-needed psychotropic (alters mood or thought) medication for R80 and R81. The CP also did not identify medication administered outside the physician ordered parameters for antihypertensive (class of medication used to treat hypertension (high blood pressure) medications for R9. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents. Findings included: - R80's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational…

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 33 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 80. The facility also failed to identify medication administered outside the physician ordered parameters for antihypertensive (class of medication used to treat hypertension (high blood pressure) medications for R9 and the lack of monitoring antihypertensive medication as physician ordered for R2. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents. Findings included: - R80's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, bipolar disorder (major mental illness that caused people to have…

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 33 residents. The sample included 12 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to provide a 14-day stop date, intended duration of therapy, and rationale for extended use related to Resident (R)24 and R80's PRN (given as needed) lorazepam (antianxiety medication that calms and relaxes people with excessive anxiety, nervousness, or tension) medication and R81's PRN trazodone (antidepressant medications used to treat mood disorders and relieve symptoms of depression) medication. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure, heart failure, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disorder (progressive and irreversible condition characterized by…

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 33 residents. The sample included 12 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure necessary information regarding Resident (R)24's care between the nursing home and hospice was availabale and known to all staff 24-hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided to R24 by hospice. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R24. Findings Included: - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure, heart failure, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disorder (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, major…

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 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to obtain food temperatures at meal times, placing the residents at risk for food borne illness. Findings included: - On 01/18/22 at 10:35 AM, during meal services, record review revealed the January temperature logs lacked documentation staff were obtaining food temperatures at meal times for the following days: 01/01/22-temperature log not provided 01/02/22-no temperatures taken of all three meals 01/03/22-no temperatures taken of all three meals 01/04/22-the supper meal temperature was not taken 01/05/22-no temperatures taken of all three meals 01/07/22-the supper meal temperature was not taken 01/08/22-the supper meal temperature was not taken 01/09/22-the supper meal temperature was not taken 01/10/22-no temperatures taken of all three meals 01/11/22-no temperatures taken of all three meals 01/12/22-the supper meal temperature was not taken 01/14/22-the supper meal temperature was not taken 01/15/22-the supper meal temperature 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.

The facility had a census of 40 residents with seven Covid (highly contagious and potentially fatal respiratory disease) positive residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement core principles of infection control practices concerning Covid when the facility failed to ensure staff were screened for signs and symptoms of Covid prior to reporting to duty in resident care areas. The facility further failed to ensure multi-use equipment was cleaned between use and failed to ensure availability of hand hygiene at screening station used by staff and visitors. The facility failed to ensure staff practiced acceptable hand hygiene measure when passing ice and delivering linens to residents' rooms. This placed the residents who resided at the facility at risk for infections. Finding included: - On 01/12/22 at 07:45 AM, upon entering the facility for health services resurvey, Social Services X greeted surveyor team at the front door. Social Services X guided survey team to the Covid screening area at the nurses'…

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 40 residents. The sample included 12 residents, with six reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services for six sampled residents, Resident (R)9, R21, R30, R137, R33, and R17. This placed the residents at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R9 recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychosis (any major mental disorder characterized by a gross impairment in reality testing), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R9's Five Day Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required limited assistance of one staff for transfers, personal hygiene, and toileting. The MDS further documented R9 required extensive assistance of one staff for bathing.…

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 40 residents. The sample included 22 residents, with 5 reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to follow the facility's Consultant Pharmacist's recommendation regarding charting of behaviors and side effects of psychotropic medication for four sampled residents, Resident (R) 9, R21, R25, and R27. Findings included: - The Electronic Medical Record (EMR) for R9 recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychosis (any major mental disorder characterized by a gross impairment in reality testing), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R9's Five Day Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required limited assistance of one staff for transfers, ambulation, dressing, and toileting. The MDS further documented R9 had delusions…

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 40 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor behaviors and side effects for four sampled residents who received psychotropic medications (medications that affect mental function and behaviors), Resident (R) 9, R21, R25, and R27. This placed the residents at risk for adverse effects and increased behaviors. Findings included: - The Electronic Medical Record (EMR) for R9 recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychosis (any major mental disorder characterized by a gross impairment in reality testing), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R9's Five Day Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required limited assistance of one staff for transfers,…

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 40 residents. The sample included 12 residents. Based on record review and interview, the facility failed to administer a pneumococcal immunization for four of six residents, Resident (R) 18, R27, R14, and R33, and failed to review and document immunization status for one of six residents, R137, reviewed for immunization status placing the residents at increased risk for infections. Findings included: - R18 received the influenza vaccine on 10/12/21. R18 completed the COVID-19 vaccine series 11/30/21. On 09/17/21 R18 signed an authorization consenting to the pneumococcal vaccine. On 01/18/22 R18 had not yet received a pneumococcal immunization. R27 received the influenza vaccine on 10/12/21. R27 completed the COVID-19 vaccine series on 11/30/21. On 09/20/21 R27 signed an authorization consenting to the pneumococcal vaccine. On 01/18/22 R27 had not yet received a pneumococcal immunization. R14 received the influenza vaccine on 10/12/21. R14 received the second COVID-19 vaccine on 11/12/21. On 09/16/21 R14 signed an authorization consenting to the…

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

The facility had a census of 40 residents with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide a completed Centers for Medicare Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) 10055 form to include estimated daily skilled service cost for three of three samples residents (or their representatives), Resident (R) 2, R8, and R17. This placed the residents (or representatives) at risk to make uninformed decisions for their Medicare skilled services. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 40 residents. The sample included 40 residents, with one reviewed for baseline care plan. Based on observation, record review, and interview, the facility failed to develop a baseline care plan for one sampled resident, Resident (R) 89, who was a new admission. This placed R89 at risk for inappropriate care. Findings included: - The Electronic Medical Record (EMR) for R89 recorded diagnoses of hypertension (high blood pressure) and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). R89's EMR recorded the resident was admitted to the facility on [DATE]. R89's EMR lacked documentation a baseline care plan was developed upon admission to the facility. On 01/13/22 at 03:30 PM, observation revealed R89 lying in bed watching television. On 01/18/22 at 10:00 AM, Administrative Nurse D verified a baseline care plan had not been developed for R89 at time of admission and stated the admitting charge nurse was responsible to complete the baseline care plan. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 40 residents. The sample included 12 residents, with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to complete a discharge summary for Resident (R) 36 that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed R36 at risk for miscommunication or interruption in the continuum of care. Findings included: - R36's medical record revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated [DATE], documented R36 had intact cognition and required limited assistance of one staff for bed mobility, transfers, toileting and extensive assistance of one staff for personal hygiene. The MDS documented ambulation did not occur during the lookback period and R36 expected to be discharged to the community. The Discharge Care Plan, dated 10/04/21, directed staff to make arrangements…

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 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure staff possessed the necessary skills and competencies necessary to assure the highest level of resident care when staff failed to assess or test Resident (R) 18 who had a change of condition and exhibited signs and symptoms of Covid (highly contagious and potentially fatal respiratory virus). This placed R18 at risk for unmet needs. Findings Included: - R18's Physician Order Sheet (POS), dated 11/26/21, included diagnoses of chronic respiratory failure with hypoxia (inadequate supply of oxygen), congested heart failure (a condition with low heart output and the body becomes congested with fluid), cardiac arrhythmia (rapid irregular heart beat), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction ((CVA) (stroke) - sudden death of brain cells due to lack of oxygen caused by…

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 40 residents. The sample included 12 residents with one reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide resident specific care for behaviors related to dementia and documenting of behaviors for Resident (R) 33, placing the resident at risk for impaired psychosocial and physical wellbeing. Finding included: - R33's Physician Order Sheet (POS), dated 11/29/21, documented diagnoses of bipolar polar disorder (major mental illness that caused people to have episodes of severe high and low moods), dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, required supervision of one staff for activities 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 had a census of 40 residents. The sample included 12 residents with one reviewed for hospice (care provided for the terminally ill). Based on observation, record review, and interview, the facility failed to collaborate care with the hospice provider for Resident (R) 27. This placed R27 at risk for unmet palliative (therapy designed to relieve or reduce intensity of uncomfortable symptoms) care needs. Findings included: - R27's Physician Order Sheet (POS), dated 11/29/21, documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, atrial fibrillation (rapid, irregular heart beat), dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance, personal history of transient ischemic attack (TIA episode of cerebrovascular insufficiency), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness 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.