Topside Manor INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 12 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Resident (R) 22 when staff did not provide her oxygen during the breakfast meal and failed to store the oxygen tubing and cannula (a medical device that delivers supplemental oxygen to patients through their nose) in a sanitary manner when not in use. This placed R22 at risk for respiratory complications. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia (a progressive mental disorder characterized by failing memory and confusion) with psychotic disturbance, depression (an abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty…

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 44 residents. The sample included 12 residents with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on observation, record review, and interview, the facility failed to provide dementia care and services for Resident (R) 22, who had dementia and behaviors. This placed R22 at risk for abuse and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia with psychotic disturbance, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), agitation (feelings of aggravation or restlessness brought on by a provocation or a medical condition), anxiety ( mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, restlessness (the inability to relax as a result of anxiety), and Chronic Obstructive Pulmonary Disease (COPD-progressive and irreversible…

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 44 residents. The sample included 12 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to prepare all the food items on the noon menu while preparing Resident (R) 20 and R22's pureed diet. This placed the residents at risk for impaired nutrition. Findings included: - On 08/27/24 at 11:22 AM, a review of the noon meal consisted of chicken parmesan, buttered penne pasta, asparagus tips, fruit crisp, and garlic toast. On 08/27/24 at 11:22 AM, Dietary Staff (DS) CC reported the Meadowlark Kitchenette had two residents who received a pureed diet. DS CC stated staff only prepared mashed potatoes and gravy for R22 at the noon meal and R20 would receive the full pureed diet. DS CC placed a 4-ounce (oz) piece of chicken parmesan into the blender container, added two (8 oz) ladles of red marinate sauce into the container, and blended it. DS CC reported it was still too thick and added another 8-oz ladle…

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 44 residents. The sample included 12 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination to Resident (R) 9 per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the resident at risk for pneumococcal infection and related complications. Findings included: - R9's admission Minimum Data Set dated 12/02/23 documented R9 admitted to the facility on [DATE]. The MDS documented R9 received the influenza (flu) vaccine before admitting to the facility. The MDs documented R9's pneumococcal vaccination was not up to date, and was not offered. A review of R9's clinical medical records lacked evidence 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 43 residents with three residents reviewed for medication errors. Based on record review and interview, the facility failed to ensure an antibiotic for a urinary tract infection (UTI-an infection in any part of the urinary system) for Resident (R) 2 was available for administration. This deficient practice placed R2 at risk for a worsening UTI and health complications. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and UTI. The Quarterly Minimum Data Set (MDS), dated 03/14/24, documented R2 had a Brief Interview for Mental Status score of three which indicated severely impaired cognition. The MDS documented R2 was dependent on staff assistance for toileting and bathing. The MDS documented R2 did not have a UTI in the last…

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 43 residents with three residents reviewed for medications. Based on record review and interview, the facility failed to monitor Resident (R) 2's psychotropic (alters mood or thought) medication used off-label use for insomnia (inability to sleep) after a trial increase. This deficient practice placed R2 at risk for inadequate oversight, lack of physician involvement, and ineffective dosing for Trazodone. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status score of three which indicated severely impaired cognition. The MDS…

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

The facility identified a census of 44 residents with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 1 respiratory needs and equipment. This deficient practice placed R1 at risk for respiratory well-being due to uncommunicated care needs. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using…

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 44 residents with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to provide appropriate care and services to provide respiratory care with the Trilogy non-invasive ventilator (an all-in-one ventilation device capable of delivering both invasive and non-invasive ventilation that can be more finely calibrated and adjusted to meet individual needs) to Resident (R) 1. The facility did not have orders from the primary care physician regarding how to run the Trilogy non-invasive ventilator, what settings the non-invasive ventilator needed to be set at, or how and when to clean the Trilogy non-invasive ventilator. This deficient practice placed R1 at risk for respiratory failure. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral…

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 44 residents with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received her pain medication as ordered to help alleviate her pain. This deficient practice placed R1 at risk of pain and emotional distress from being in pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using an artificial airway). The MDS…

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

The facility identified a census of 44 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 was free from medication errors. This deficient practice placed R1 at risk of medical complications from not receiving her medications as they were ordered by her physician. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polyneuropathy (the simultaneous malfunction of peripheral nerves throughout the body), chronic pain, hypokalemia (low level of potassium in the blood), and edema (swelling). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required oxygen and a non-invasive ventilator (a machine that provides ventilatory support without using 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 had a census of 41 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week, placing all the residents who resided at the facility at risk of lack of assessments and inappropriate care. Finding included: - Review of Payroll Based Journal (PBJ- a required detail information submitted by nursing homes of staffing required from the Centers of Medicare and Medicaid Services[CMS]) revealed the facility lacked RN eight-hour coverage for the months of August 2022, September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, and August 2023. On 08/30/23 12:38 PM, Administrative Nurse D verified the days without eight consecutive RN coverage a day in the months listed above. Upon request, the facility did not provide a policy for eight consecutive RN daily coverage. On 08/30/23 Administrative Staff A stated the CMS requirements would be considered the policy. The facility failed to provide…

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 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with meaningful resident centered interventions for falls for Resident (R) 31, and R34. The failed to revise the care plan related to mood for R23 and R2. This placed the resident's at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of history of falls, lack of coordination, diastolic heart failure (a condition in which the hearts main pumping chamber becomes still and unable to fill properly), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R31 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.

The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for one of three households. The facility staff failed to change gloves after touching their clothing, doors, papers, and other objects, and touched pancakes with the same contaminated gloves. This placed the residents at risk for food borne illness in two of three households. Findings included: On 08/29/23 at 08:30 AM, observation in the Cottonwood Household revealed Dietary Staff CC wore gloves as she prepared breakfast. Further observation revealed DS CC picked up a pancake and moved it to the side of the plate with her gloved hands so that she could pour syrup on the bottom pancake. She went to a drawer with clothing protectors, opened it and put the protector on a resident. DS CC went to a resident room with the same soiled gloves and returned with a dirty cup that she put on the kitchen cabinet. DS CC touched paper in a notebook, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to notify the physician of Resident (R) 2's suicidal ideations, R7's elopement ( when a resident exits the facility without the knowledge or supervision of staff) in winter weather, R13's lack of bowel movements and R23's verbalizations of wanting to die. This placed the residents at risk for delayed treatment due to lack of physician involvement. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular heart beat), need of assistance with personal care, and urinary tract infection (UTI). The 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 had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to identify Resident (R)27's leaving the facility without the knowledge of staff in the middle of the night as an allegation of neglect and report to the state agency as required. This placed R27 at risk for unidentified and/or ongoing neglect. Findings included: -The Electronic Medical Record (EMR) documented R27 had diagnoses of restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal cares, adjustment disorder with depressed mood, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormalities of gait and mobility, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R27 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)27's incident of tweezers in her throat as well as R27 exiting the facility without staff awareness during winter weather. This failure placed R27 at risk for ongoing neglect and unidentified care needs. Findings included: -The Electronic Medical Record (EMR) documented R27 had diagnoses of restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal cares, adjustment disorder with depressed mood, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormalities of gait and mobility, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R27 had severe cognitive impairment, 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 had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice when a Certified Nurse Aide (CNA) used tweezers to remove a blackhead on Resident (R)19's back without instruction or supervision from a licensed nurse, and the facility further failed to provide a dressing change to R31's wrist when sanguineous drainage (leakage of fresh blood) seeped through the dressing. This placed the residents at risk for inappropriate skin care and related complications. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), sebaceous cyst (a small, slow-growing, noncancerous bump beneath the skin), anxiety (mental or emotional reaction charactered by apprehension, uncertainty and irrational fear, and polyneuropathy (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 had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice when staff failed to monitor and provide pain medication to Resident (R)16, who had severe pain in her shoulder after an incident with the sit to stand lift. This placed the resident at risk for prolonged pain. Findings included: - The Electronic Medical Record (EMR) for R16 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and pain. The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of three staff for bed mobility, transfers, toileting; R16 did not ambulate. The MDS further documented R16 rarely had pain and received non medication interventions for pain. The Pain Interview Assessment, dated 05/23/23,…

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 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide the appropriate treatment and services to attain the highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being when staff failed to provide Resident (R)2 with mental health services when reporting suicidal ideations. This placed R2 residents at risk for unmet mental health care needs. Findings included: -The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular heart beat), need of assistance with personal care, and urinary tract infection (UTI). 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 had a census of 41 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two sampled residents, Resident (R) 2 who had reported suicidal ideations and lacked social service involvement, and R23 who reported wanting to die and social services was not aware of reported concern. This placed the residents at risk for further decline of their emotional and mental well-being. Findings included: - The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic pain, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity, difficulty or discomfort in breathing), altered mental status, chronic atrial fibrillation (rapid, irregular…

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 41 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to provide physician ordered medications for lack of bowel movements, and failed to contact the physician for one resident, Resident (R) 13, who had a history of constipation. This placed the resident at risk for impaction. Findings inlcuded: - The Electronic Medical Record (EMR) for R13 documented diagnoses of constipation (difficulty passing stool), chronic pain (pain that carries on for longer than 12 weeks despite medication or treatment), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition and required extensive assistance of two staff for bed mobility, 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 41 residents. Based on observation, record review, and interview, the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance, when dietary staff failed to follow a recipe while preparing a pureed (texture-modified diet in which all food to have a soft, pudding like consistency) diet for one resident in the Cottonwood Household and failed to prepare foods by methods that conserve palatable and nutritive value by serving beef steak at incorrect temperature and the nutritive value by omitting a vegetable serving to two residents who received pureed diets in the Sunflower Household. This placed the resident's at risk for unmet dietary needs and at risk of foodborne illness. Findings included: - On 08/29/23 at 12:31 PM, observation revealed Dietary Staff CC prepare the pureed meal for one resident. DS CC blended in an industrial blender, a beef cube steak, two unmeasured scoops of brown gravy and unmeasured amount of milk. Continued observation revealed DS CC did not obtain a temperature 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 had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure essential equipment was maintained in safe operating condition. This placed the residents who used the lift at risk for preventable accidents. Findings included: - The Electronic Medical Record (EMR) for R16 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and pain. The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of three staff for bed mobility, transfers, toileting; R16 did not ambulate. The MDS further documented R16 rarely had pain and received non medication interventions for pain. The Pain Care Plan, dated 06/09/23, initiated on 08/02/21, documented R16 had chronic pain and directed staff to administer pain medication, reposition R16, and monitor for response 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 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare and serve food in accordance with professional standards for the 34 residents who received their meals from the facility kitchen. This placed the 34 residents at risk for foodborne illness. Findings included: - On 03/14/22 at 10:22 AM, observation revealed in the two door refrigerator labeled (kitchen) a metal pan with bagged scrambled and boiled eggs, with packages of sliced ham, and sausage on top of the eggs on the top shelf. On 03/14/22 at 11:31 AM, observation revealed in the walk in refrigerator in the kitchen three five pound (lb) low fat cottage cheese containers with an expiration date of 03/12/22. On 03/14/22 at 11:56 AM, observation revealed the following: A kitchen ceiling vent by the storage room had blackish lint. The kitchen cabinets had numerous areas with dried food drippings. All around the kitchen the mopboard had brownish gray grime approximately 2 inches x 2 inches. The inside kitchen door 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 had a census of 34 residents. The sample included 12 residents of which four were reviewed for respiratory care. Based on observation, record review, and interview, the facility staff failed to provide necessary respiratory care and services for Resident (R) 1, R5, R19, and R27, when staff stored their uncovered nebulizer masks on top of their nebulizer machines. This placed R1, R5, R19, and R27 at increased risk for complications and respiratory infection. Findings included: - R1's Electronic Medical Record (EMR) documented she had diagnoses of shortness of breath, chronic atrial fibrillation (rapid, irregular heart beat ), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R1's Significant Change Minimal Data Set (MDS), dated [DATE] documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required total staff assistance with locomotion off 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 had a census of 34 residents. The sample included 12 residents of which two were reviewed for dignity. Based on observation, record review and interview the facility failed to treat Resident (R) 3 and R1 with respect and dignity during care, placing the residents at risk for embarrassment and an undignified environment. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). R3's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition, required extensive staff assistance with bed mobility, and transfers. R3 had functional impairment in the left lower extremity, and was incontinent of bowel and bladder. The Incontinence Care Plan, dated 02/17/22, directed the staff to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) for Resident (R) 3. This placed the resident at risk for elevated blood sugars and adverse side effects. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus. The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated 02/17/22, recorded R3's cognition fluctuated and R3 had poor decision making skills. Review 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 had a census of 34 residents. The sample included 12 residents, with two reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent skin breakdown for one sampled resident, Resident (R) 20, who had a Stage 2 (partial thickness loss) pressure ulcer. This placed R20 at risk for further skin breakdown. Findings included: - The Electronic Medical Record (EMR) for R20 documented diagnoses of dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). R20's…

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 34 residents. The sample included 12 residents, with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide appropriate cares to prevent shearing when repositioning for one sampled resident, Resident R (1), placing the resident at risk for skin injury. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), chronic pain (persistent pain that lasts weeks to years and may be caused by inflammation or dysfunctional nerves), vitamin deficiency (a condition of a long-term lack of a vitamin), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and fracture of the right humerus (upper arm bone is broken). The Significant Change Minimum Data Set (MDS), dated 12/22/21, documented the resident had intact cognition and required extensive assistance of two staff for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, record review and interview, the facility failed to provide a safe environment for one of the five sampled residents, Resident (R) 3 who recently had a hip fracture (broken bone). This placed the resident at risk for further accidents. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning),and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated 02/17/22, recorded R3's cognition fluctuated 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 34 residents. The sample included 12 residents, with four reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide necessary nutritional assessments and treatment for weight loss for one of four residents, Resident (R) 31. This placed the resident at risk for further weight loss and decline. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of dementia without behavioral disturbance (progressive disorder characterized by failing memory and confusion), small cell carcinoma of the lung (an aggressive fast growing cancer that forms in tissues of the lung and can spread to other parts of the body), hypothyroidism (condition characterized by hyperactivity of the thyroid gland), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness). R31's Quarterly Minimum Data Set, dated 02/03/22, documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding Resident (R) 3's antidiabetic medications (medication to stabilize blood sugar) and the lack of associated blood sugar monitoring. This placed R3 at risk for adverse outcomes including hypoglycemia (low blood sugar). Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor blood sugar for one of five sampled residents, Resident (R) 3 who received routine antidiabetic medications (medication to stabilize blood sugar). This placed R3 at risk for adverse medication side effects. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition, required extensive staff assistance with bed mobility, transfers, and had functional impairment in the left lower extremity. The Cognitive Loss Care Area Assessment (CAA), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to exercise adequate infection control measures when they failed to utilize proper hand hygiene and failed to handle soiled trash appropriately during direct care for Resident (R) 3. The facility further failed to ensure staff used adequate personal protective equipment while administering an insulin (a medication to stabilize blood glucose) injection. This placed the affected residents at increased risk for infectious disease and illness. Findings included: - R3's Physician Order Sheet (POS), dated 02/11/22, recorded diagnosis of left femur fracture (broken hip bone), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus ( a chronic condition that affects the way the body processes blood sugar). R3's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired…

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