Medicalodges Fort Scott

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents. The sample included three residents. Based on observation, interview, and record review the facility failed to update Resident (R) 1's Care Plan, putting the resident at risk for inadequate care due to uncommunicated care needs. Findings included: - R1's Electronic Medical Record (EMR) included the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), major depressive disorder (MDD-major mood disorder that causes persistent feelings of sadness), intellectual disability (ID- a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and 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 reported a census of 26. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), and ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), remain free from neglect when Certified Medication Aide (CMA) S continued to administer R1's morning medications despite R1's request to slow down because she was having a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying. Findings included: - (R)1's ''Physician Order Sheet'' (POS), dated 08/01/24, documented diagnoses which included: dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), ileus (obstruction of the intestines [gastrointestinal tract that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), remain from neglect when Housekeeping U and Outside Resource Staff EE failed to report to Administrative Staff A that Certified Medication Aide S continued to administer R1's morning medications despite R1's request to slow down because she was had a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying. Findings included: - (R)1's ''Physician Order Sheet'' (POS), dated 08/01/24, documented diagnoses which included: dysphagia (swallowing difficulty), oropharyngeal phage (delay in…

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

The facility identified a census of 37 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. This placed the residents at risk for impaired mental and physical well-being. Findings included: - A review of the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) for Fiscal Year (FY) 2023 Quarter 4 and FY 2024 Quarter 1 revealed the facility triggered for excessively low weekend staffing. On 04/03/24 at 10:15 AM, Resident Council members reported activities rarely occurred on weekends compared to the weekdays. The council reported due to the low staffing in the facility there was no activity person on the weekend. The council reported they would like activities on the weekends, such as bingo or interactive groups on the weekend. On 04/03/24 at 10:37 AM Administrative Staff A stated the weekend staff was low at times related to call-ins and lack of staff. Administrative Staff A stated the weekend staff had improved. On 04/03/24…

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 had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA Q, hired on 11/24/98 had no yearly performance evaluations upon request. CNA M, hired on 05/14/19 had no yearly performance evaluations upon request. CNA BB, hired on 05/22/20 had no yearly performance evaluations upon request. CNA R, hired on 06/28/22 had no yearly performance evaluations upon request. CNA S, hired on 11/17/97 had no yearly performance evaluations upon request. On 04/02/24 at 04:02 PM Administrative Staff A stated the facility was unable to find any performance evaluations or the required in-service records for 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 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNAs) reviewed for 12 hours of required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA Q, hired on 11/24/98 had no hours of in-service training recorded. CNA M, hired on 05/14/19 had no hours of in-service training recorded. CNA BB, hired on 05/22/20 had no hours of in-service training recorded. CNA R, hired on 06/28/22 had no hours of in-service training recorded. CNA S, hired on 11/17/97 had no hours of in-service training recorded. On 04/02/24 at 04:05 PM Administrative Staff A stated the facility was unable to find any performance evaluations or the required in-service records for the above-mentioned staff. On 04/03/24 at 03:30 PM…

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, observation, and interviews, the facility failed to post the State Survey Agency (SSA) contact information on how to report abuse in a manner accessible to the residents and their representatives. This deficient practice placed the residents at risk for ongoing abuse and other concerns. Findings Included: - On 04/01/24 at 07:20 AM a walkthrough of the facility was completed. Upon inspection of the facility's television area, a small 8-inch by 10-inch (8x10) poster with small black writing was posted by the main entry door to the room four feet high on the wall. The poster displayed the SSA contact information and instructions related to reporting complaints related to abuse. A walkthrough of the center hall revealed an 8x10 poster with a small black font on the wall placed behind two Hoyer lifts (total body mechanical lift). The poster was placed six feet away from the view of the hall. On 04/02/24 at 10:15 AM, the Resident Council members reported they were not aware 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.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 04/02/24 at 08:00 AM an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 04/02/24 at 10:15 AM, the Resident Council members reported they were not aware if the facility provided a way to complete anonymous grievances. The council reported Administrative Staff A was responsible for complaints and grievances. The council reported they did not know of a grievance box or forms. On 04/03/24 at 11:45 AM Social Services X reported she was not aware of any way for the residents or their visitors to file grievances anonymously. On 04/03/24 at 03:50 PM Administrator 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 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan with resident-specific interventions for Resident (R)7, R10, R25, and R14. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of morbid obesity (severely overweight), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and respiratory failure. R7's Quarterly Minimum Data Assessment (MDS) completed 02/02/24 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated he required substantial to maximal assistance with bed mobility, transfers, personal hygiene,…

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 includes 12 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being. Findings included: - A review of the facility's Activity Calendar for January, February, and March 2024 was completed. The review revealed no activities on Saturdays and Sundays. The calendar indicated church services were provided on Sunday afternoons. On 04/03/24 at 10:15 AM, Resident Council members reported activities rarely occurred on weekends compared to the weekdays. The council reported due to the low staffing in the facility there was no activity person on the weekend. The council reported they could read books, and there were extra coloring pages, or they could watch TV. The council reported they would like activities on the weekends, such as bingo or interactive groups on the weekend. On 04/03/24 at 12:55 PM, Certified Nurses Aid (CNA) Q stated staff used to have activities 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 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous materials for eight cognitively impaired independently mobile residents. The facility additionally failed to assess and ensure Resident (R) 25's siderails were mounted safely. This deficient practice placed the affected residents at risk for preventable accidents. Findings Included: - On 04/01/24 at 07:05 AM a walkthrough of the facility was completed. An inspection of the facility's east hallway revealed an unlocked oxygen storage room. An inspection of the room revealed 25 pressurized supplemental oxygen cylinders stored on the racks. The room contained eight smaller pressurized cylinders underneath a shelf. Certified Nurses Aid (CNA) O stated the room should be left secured due to the oxygen canisters and secured the door. An inspection of the north hallway revealed an unsecured beauty shop. The room 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.

The facility identified a census of 37 residents. The sample included 12 residents. Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards related to following enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care), laundry services, and sanitary care practices. his deficient practice placed the residents at risk for infectious diseases. Findings Included: - The facility identified it was completing ongoing exposure testing for COVID-19 (highly contagious, potentially life-threatening respiratory virus) but had no COVID-19-positive residents in the facility. A review of Resident (R)2's Electronic Medical Record (EMR) indicated she had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). Her EMR lacked indication she was on enhanced barrier precautions. A review of R4's EMR indicated he had a percutaneous endoscope gastrostomy tube (PEG-a tube…

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

The facility identified a census of 37 residents. The sample included 12 residents. Based on records review, interviews, and observations, the facility failed to provide effective pest control so that the facility was free from pests. This placed the residents at increased risk for impaired comfort and disease. Finding Included: - An inspection of the facility's Pest Siting log indicated that cockroaches were last seen in the facility on 07/07/23 around the north hall soiled utility room. The pest control log indicated the facility contracted a company to spray monthly. The log indicated the last pest control treatment was in March 2024. On 04/01/24 at 07:01 AM a walkthrough of the facility was completed. An inspection of an unlocked shower room labeled Handicapped Women's Bathroom (north hall) revealed a large number of cockroaches crawling along the shower, toilet, cabinets, sink ceiling, and bathtub in the room. On 04/03/24 at 02:30 PM, Licensed Nurse (LN) G stated she was aware the facility had large numbers of cockroaches. She stated staff reported the north hall bathroom 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 identified a census of 37 residents with 12 residents included in the sample. The facility identified six residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 88 and R 89. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - A review of R88's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/09/23 and ended on 12/21/23. R88 did not remain in the facility for custodial care. The facility was unable to provide documentation a NOMNC was issued for R88. A review of R89's EMR documented that the Medicare Part A episode began on 9/27/23 and ended on 11/03/24. R89 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.

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 hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notice of transfer or discharge notice for Resident (R) 10's facility-initiated transfers. This deficient practice placed R10 at risk of uninformed choices and miscommunication regarding care needs. Findings included: - R10'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), hypertension (HTN-elevated blood pressure), and a contracture (abnormal permanent fixation of a joint or muscle). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented no upper or lower extremity impairment for R10 during the observation period. The Quarterly 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 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold notice when Resident (R) 10 was hospitalized . This deficient practice placed R10 at risk of uninformed choices. Findings included: - R10'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), hypertension (HTN-elevated blood pressure), and a contracture (abnormal permanent fixation of a joint or muscle). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented no upper or lower extremity impairment for R10 during the observation period. The Quarterly MDS dated 02/16/24 documented a BIMS score of 10 which indicated moderately 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 identified a census of 37 residents. The sample included 12 residents with three residents reviewed for activities of daily living (ADL). Based on record review, and interviews, the facility failed to ensure Resident (R) 25 received the necessary ADL assistance he required for his hearing aids. This deficient practice placed R25 at risk for the inability to communicate with peers or staff, increased confusion, negative psychosocial outcomes, and decreased dignity. Findings included: - R25'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), hypertension (HTN-elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cognitive communication deficit. The Significant Change Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition. The MDS documented R25 was dependent on staff assistance…

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 37 residents. The sample included 12 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for fluid overload for Resident (R) 14. This deficient practice placed R14 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R14'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), neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or never problems), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). The Significant Change Minimum Data Set (MDS) dated [DATE] did not document a Brief Interview of Mental Status (BIMS). The MDS documented that R14 required…

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 37 residents. The sample included 12 with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)7's pressure-reducing interventions were implemented correctly when his low air-loss mattress pump was inappropriately set for his current weight. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of morbid obesity (severely overweight), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and respiratory failure. R7's Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R10 at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R10'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), hypertension (HTN-elevated blood pressure), and a contracture (abnormal permanent fixation of a joint or muscle). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infections (UTI infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)2 received sanitary catheter care when staff failed to provide R2 education on performing sanitary catheter care and failed to assess R2's ability to self-perform her catheter care. These deficient practices placed the resident at risk for catheter-related complications. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, acute respiratory failure (occurs when your lungs cannot release enough oxygen you're your blood, which prevents your organs from properly functioning) with hypoxia (hypoxia (inadequate supply of oxygen), diabetes mellitus…

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 with two reviewed for nutrition. Based on record review, observations, and interviews, the facility failed to obtain accurate weights as ordered by the medical provider to prevent avoidable weight loss for Resident (R)4. This deficient practice placed R4 at risk for complications related to weight loss. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and abnormal weight loss. R4's admission Minimum Data Assessment (MDS) completed 03/04/24 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated he weighed 139 pounds (lbs.) upon admission. The MDS indicated he had an enteral feeding tube (provision of nutrients…

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 37 residents. The sample included 12 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure appropriate respiratory care and services for Resident (R)33 and R2. This placed the residents at risk for respiratory complications. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of pulmonary edema (accumulation of extravascular fluid in the lung tissues), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (HTN-elevated blood pressure) and weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severe cognition impairment. The MDS indicated R33 needed assistance with activities of daily living (ADLs). The MDS indicated R33 did…

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 37 residents. The sample included 12 residents with one resident reviewed for siderails. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 25 had documented consent for the use of the siderails, failed to show alternative methods were attempted, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the siderails. This placed the resident and/or representative at risk for uninformed decisions related to the risks and benefits associated with the use of siderails. Findings included: - R25'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), hypertension (HTN-elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cognitive communication deficit. The Significant Change…

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 with one reviewed for significant medication errors. Based on interviews and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to administer Resident (R)30's Midodrine (medication used to increase blood pressure). This deficient practice placed R30 at risk for impaired quality of care. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of hypotension (low blood pressure), muscle weakness, major depressive disorder (major mood disorder), and aphasia (condition with disordered or absent language function). R30's admission Minimum Data Assessment (MDS) completed 03/15/24 noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to severe impairment. The MDS indicated she was dependent on staff assistance for all activities of daily living (ADLs). The MDS indicated she had respiratory services. R30's Communication Care Area Assessment (CAA) completed 03/21/24 indicated she had…

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 37 residents. The sample included 12 residents. with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the need for physician documented rationale for the continued use of the antipsychotic medication for Resident (R) 3 who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion). The facility also failed to follow the recommendations of the CP related to R30's Midodrine administration given outside of the physician-provided parameters repeatedly. This deficient practice placed R30 at risk for adverse medication effects. Findings included: - R3's Electronic Medical record (EMR) under the 'Diagnoses tab recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition…

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 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate pulse monitoring for Resident (R)4's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure). The facility additionally failed to obtain physician-ordered lab results for R3's medication regimen. These deficient practices placed the residents at risk for unnecessary medications and adverse medication effects. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and abnormal weight loss. R4's admission Minimum Data Assessment (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 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)3's olanzapine (antipsychotic medication). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R3's Electronic Medical record (EMR) under the 'Diagnoses tab recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart…

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 with one reviewed for significant medication errors. Based on interviews and record reviews, the facility failed to prevent a significant medication error for Resident (R)30 when staff administered Midodrine (medication used to increase blood pressure) outside of the physician-provided parameters repeatedly. This deficient practice placed R30 at risk for adverse medication effects. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of hypotension (low blood pressure), muscle weakness, major depressive disorder (major mood disorder), and aphasia (condition with disordered or absent language function). R30's admission Minimum Data Assessment (MDS) completed 03/15/24 noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to severe impairment. The MDS indicated she was dependent on staff assistance for all activities of daily living (ADLs). The MDS indicated she had respiratory services. R30's Communication Care Area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents. 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, and a failed to describe the services and equipment provided to Resident (R) 25 by hospice. This deficient practice created a risk for missed or delayed services and impaired care for R25. Findings included: - R25'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), hypertension (HTN-elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cognitive communication deficit. The Significant Change Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition. The MDS documented R25 was dependent…

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 37 residents. The sample included 12 residents with five reviewed for pneumococcal (type of bacterial infection), and influenza (highly contagious viral infection immunizations. Based on record review and interviews, the facility failed to provide consent, declination, or documentation of ineligibility for Resident (R)2, R19, and R33's pneumococcal vaccinations. This deficient practice placed the residents at risk for complications related to pneumococcal diseases. Findings Included: - On 04/02/24 at 10:03 AM a review was completed related to pneumococcal and influenza vaccinations for R2, R7, R19, and R33. R2's Electronic Medical Record (EMR) indicated she was admitted to the facility on [DATE]. The EMR indicated she refused the Prevnar 13 (07/2017) and Pneumovax 23 (09/2018) vaccinations. The EMR indicated she received an unidentified pneumococcal vaccination from the Kansas Department of Health and Environment (KDHE) on 12/05/22. The EMR lacked consent, declination, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents with five reviewed for COVID-19 (highly contagious viral infection) immunizations. Based on record review and interviews, the facility failed to provide consent, declination, or documentation of ineligibility for Resident (R)3's COVID-19 immunizations. This deficient practice placed the residents at risk for complications related to COVID-19. Findings Included: - On 04/02/24 at 10:03AM a review was completed related to COVID-19 immunization for R2, R3, R7, R19, and R33. R3's EMR indicated she was admitted to the facility on [DATE]. The EMR lacked documentation indicating she received or was offered COVID-19 immunizations. The EMR indicated she had no COVID-19 vaccinations. The EMR lacked consent, declination, or documentation of ineligibility for her COVID-19 vaccinations. The EMR lacked documentation related to the education provided and the risks associated with the vaccinations ordered. On 04/02/24 at 03:05 PM Administrator A…

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

The facility reported a census of 50 residents. Based on observation, interview and record review, the facility failed to ensure an effective infection control and prevention program to prevent the spread of infection. Findings included: - Interview, on 08/30/22 at 08:00 AM, with Administrative staff A, revealed the facility had one Covid positive resident and the facility was in outbreak testing. Observation, on 08/30/22 at 08:00 AM, revealed the screening desk area at the front entrance adjacent to the common living area, contained approximately 12 completed rapid tests across one end of the desk. Observation of the hallway outside of a resident room with active Covid, revealed three isolation gowns thrown over the hand rails, and a large plastic bags that contained clean cloth isolation gowns directly on the floor beside the biohazard trash can. Observation on 08/30/22 at 08:45 AM, revealed Certified Nurse Aide (CNA) M in preparation to enter the resident's (in isolation for active Covid,) room to deliver her breakfast. CNA M could not locate a N95 masks (a specific mask type 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 reported a census of 50 residents. Based on record review and interview, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship in a proactive manner to ensure residents received antibiotics in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance. The facility failed to track and trend causative microorganisms to determine trends within the facility. Findings included: - Review of the Infection Control Surveillance Logs revealed the following areas of concern: Review of the January 2022 log revealed seven urinary tract infections all lacking causative organisms to determine appropriateness of antibiotic use. Review of the February 2022 log revealed nine urinary tract infections, five with cultures done, one of the five indicated causative organism. One of the urinary tract infections without causative organism had been treated with Meropenem (a broad-spectrum antibiotic) for 21 days. Review of the March 2022 log revealed three urinary tract infections, one with culture results,…

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. The sampled of 16 residents included eight reviewed for Covid-19 vaccinations. Based on interview and record review, the facility failed to ensure eight of the eight sampled residents were offered the second vaccine booster which became available on May 20, 2022 in a timely manner as required and/or failed to monitor the residents' vaccine status for possible booster administration. Findings included: - Review of the Immunization Report revealed the following areas of concern for Covid-19 vaccination status: Unsampled Resident (R) 18, last Covid-19 booster received on 11/30/21. Unsampled R30, last Covid-19 booster received on 10/28/21. R 19, last Covid-19 booster received on 11/22/21. Unsampled R 26, last Covid-19 booster received on 10/27/21. R 10, last Covid-19 booster received on 11/22/21. R2, last Covid-19 booster received on 11/19/21. R 24, last Covid-19 booster received on 12/31/21. R6, last Covid-19 booster received on 11/08/21. Interview, on 09/06/22 at 10:45 AM, with Administrative Staff A, revealed the facility did not offer…

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, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly environment in the storage closets that contained supplies for the residents of the facility. Findings included: - During an environmental tour on 09/01/22 at 09:46 AM, with Housekeeping/Maintenance staff U, the following concerns identified: 1.) A storage closet near the kitchen had a partial box of dinner napkins, a full box of 1,000 plastic lids, a 16-pack box of paper towels and a partially full box of plastic lids, stored directly on the floor. 2.) A storage room on the north hall had a full box of ostomy (surgical creation of an artificial opening on the intestinal wall to excrete feces from the body) supplies, two partial boxes of humidifier bottles, a case of Nutren 1.5 (a liquid nutritional replacement), a partial box of wound Vacuum-assisted closure (VAC) supplies, a full box of foley (a tube inserted into the bladder to drain urine in a collection bag) supplies, a case of six…

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, 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. Findings included: - During an environmental tour on 09/01/22 at 09:46 AM, with Housekeeping/Maintenance staff U, the following concerns identified: 1. Sunflower hall shower room had a toilet seat riser with rust on two of the four legs. The shower room also had a shower chair with a heavily worn mesh back. 2. One resident room had large holes in the cove base as well as multiple gaps and scraped areas on the cove base, ranging in size from 1 inch to 3 feet. 3. One resident room had paint missing on the bathroom and closet doors, in multiple areas. 4. One resident room had a large piece of wooden windowsill, approximately eight inches long, broken away. The wall behind the recliner was heavily damaged and missing paint, in an approximately two-foot area. There was broken floor tile underneath the air conditioning unit, in about 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 - Review of Resident (R)24's electronic medical record (EMR), under the Med (Medical) Diag (diagnosis) tab, included 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 eight, indicating moderately impaired cognition. She required extensive assistance of two staff for transfers and had no limitation in range of motion (ROM). The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/24/22, documented the resident was able to make her needs known. She required extensive assistance of staff for transfers. The quarterly MDS, dated 07/23/22, documented the resident had a BIMS score of nine, indicating moderately impaired cognition. She required extensive assistance of two for transfers and 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 50 residents with 16 residents sampled, including three residents reviewed for Activities of Daily Living (ADL). Based on interview, record review and observation, the facility failed to ensure two Residents (R)21, and R 25, received appropriate personal hygiene, regarding facial shaving. Findings included: - Review of Resident (R)25's electronic medical record (EMR), under the Med Diag (medical diagnoses) tab, included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission MDS, dated 06/19/22, documented the resident had a BIMS score of zero, indicating severe cognitive impairment. He required extensive assistance of one staff for personal hygiene. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. He required extensive assistance of two staff for personal hygiene. The Activities…

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 16 residents selected for review, which included two residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure one of the two selected Residents (R) 13, received appropriate monitoring and treatment and preventive measures for pressure ulcers. Findings included: - Review of Resident (R)13's Physician Order Sheet, dated 08/19/22, revealed diagnoses included open wound of lower back and pelvis, emphysema (long-term, progressive disease of the lungs characterized by shortness of breath,) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness.) The admission Minimum Data Set (MDS) status as In Progress. Review of the electronic medical record revealed the following admissions to the facility: admission to the facility 04/18/22 with discharge on [DATE]. admission to the facility 06/16/22 with discharge on [DATE] with transfer to assisted…

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 16 residents sampled, including four residents reviewed for accidents. Based on interview, record review, and observation, the facility failed to ensure staff provided safe transfers for one Resident (R)24, of the four residents reviewed for accidents. Findings included: - Review of Resident (R)24's electronic medical record (EMR), under the Med (Medical) Diag (diagnosis) tab, included 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 eight, indicating moderately impaired cognition. She required extensive assistance of two staff for transfers and had no limitation in range of motion (ROM). The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA),…

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 resident with 16 selected for review which included two residents reviewed for urinary catheter. Based on observation, interview and record review, the facility failed to ensure sanitary catheter care for one of two residents (R) 12, reviewed for catheter care. Findings included: - Review of Resident (R)12's Physician Order Sheet, revealed diagnoses included diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, and the resident required limited assistance of one staff for transfers and personal hygiene and extensive assistance of one staff for toileting. The resident had no impairment of the upper or lower extremities and used a wheelchair for mobility. The resident had a urinary catheter (insertion of a catheter into…

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. The sample of 16 residents included two residents which received their total nutrition and hydration through a percutaneous enteral gastrostomy feeding tube, (PEG- a tube that directly enters the stomach through the abdominal wall). Based on observations, interviews, and record review, the facility failed to ensure one Resident (R)19 received appropriate treatment and services to prevent potential complications and/or metabolic interactions related to the resident's tube feeding and mixture of his medications through his PEG tube. Findings included: - Review of Resident (R)19's Physician Orders, dated 08/09/2022, revealed diagnoses which included, encephalopathy (inflammatory condition of the brain), gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall), aspiration (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), dementia (progressive mental disorder characterized by failing memory,…

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, which included one resident sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice and person -centered care plan for one Resident (R)19, related to storage and tubing/mask change of oxygen equipment. Findings included: - Review of Resident (R)19's Physician Orders, dated 08/09/2022, revealed diagnoses which included, encephalopathy (inflammatory condition of the brain), dementia (progressive mental disorder characterized by failing memory, confusion), aphasia (condition with disordered or absent language function), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), atrial fibrillation (irregular heart rate), epilepsy (seizures), insomnia (inability to sleep), pneumonia (inflammation of the lungs) , and hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 50 residents with 16 selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure staff monitor bowel movements and administer laxatives for two of the five Residents (R) 3 and R21. Furthermore, the facility failed to obtain laboratory results to monitor the effectiveness of medications for one of the five residents, R22. Findings included: - Review of Resident (R)3's undated Physician Order Sheet, revealed diagnoses included unspecified injury of the cervical spine, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) with neuropathy (nerve damage causing weakness and pain), constipation (difficulty passing stools), and arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal…

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.