Via Christi Village Hays Ks LLC

The facility had a census of 84 residents. The sample included 27 residents, with one reviewed for foot care. Based on observation, record review, and interview, the facility failed to provide foot care to one resident, Resident (R) 49, whose toenails were long and over the top of her toes. This placed the resident at risk for complications, poor hygiene, discomfort, and injuries.Findings included:- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure).The Quarterly/Five Day Medicare Minimum Data Set (MDS). dated 04/21/25, documented R49 had intact cognition. R49 required staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 had upper functional impairment on one side, lower functional impairment on both sides, and required assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 84 residents. The sample included 27 residents, with nine reviewed for nutrition and weight loss. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent weight loss for Residents (R) 20. This deficient practice resulted in significant weight loss and placed the resident at risk for further weight loss or health issues.Findings included: - R20's Electronic Health Record (EHR) revealed diagnoses of Extended spectrum beta lactamase (ESLB, an infection cause by a bacteria that produces extended-spectrum beta- lactamases enzymes that make certain antibiotics effective such as e coli and klebsiella, making the infection harder to treat and can occur in urinary tract infections or bloodstream infections,) congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), chronic kidney disease Stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid…

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 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store oxygen cannula, nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs), and a continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) equipment in sanitary conditions for Resident (R) 12, which placed the resident at risk of respiratory infections.Findings included:- R12's Electronic Medical Record (EMR) included the diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pain, acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and age-related physical…

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 84 residents. The sample included 27 residents, with one reviewed for competent staffing. Based on observation, record review, and interview, the facility failed to ensure staff possessed the appropriate skills and knowledge to monitor and communicate nursing orders, while waiting for direction from the physician, for one resident, Resident (R) 49, who sustained two open areas from an immobilizer. This placed the resident at risk for further breakdown.- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure).The Quarterly/Five Day Medicare Minimum Data Set (MDS), dated [DATE], documented R49 had intact cognition. R49 was dependent upon staff assistance for lower body dressing, bathing, transfers, mobility, 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 84 residents. The sample included 27 residents, of whom one was reviewed for the provision of mental-related social services. Based on observation, record review, and interview, the facility failed to provide adequate medical social services to meet Resident (R) 37's medical health needs. This placed the resident at risk for decreased quality of care and life.Findings included:- R37's Electronic Medical Record (EMR) documented R37 had a diagnosis of arthritis (inflammation of a joint characterized by pain, swelling, redness, and limitation of movement). R37's Quarterly Minimum Data Set (MDS), dated [DATE], documented R37 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident was independent with eating, had broken or loosely fitting full or partial dentures.R37's Care Plan, revised 07/03/25, documented R37 was edentulous and instructed staff to assess dentures for proper fitting, assist as needed with oral care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 84 residents. The sample included 27 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to recommend to the physician or the facility's Director of Nursing (DON) a gradual dose reduction (GDR -tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident (R) 28's psychotropic (a class of medications that alters mood or thought) medication. The facility failed to ensure the physician provided the risk versus benefit for the continued use of buspirone (anti-anxiety) medication. This deficient practice placed R28 at risk of unnecessary medication administration and related complications. Findings included:- R28's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty 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 84 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 49. This placed the resident at risk for physical decline and other related complications.Findings included:- The Electronic Medical Record (EMR) for R49 documented diagnoses of hypertension (high blood pressure), atrial fibrillation (rapid heart rate), and diastolic congestive heart failure (occurs when the left ventricle stiffens and can't fill with blood properly between heartbeats).The Quarterly/Five Day Medicare Minimum Data Set (MDS), dated [DATE], documented R49 had intact cognition. R49 was dependent upon staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 received antidepressant (a class of medications used to treat mood disorders,…

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 36 residents. Based on observation, interview, and record review, the facility failed to store biologicals as required when staff failed to discard or destroy expired medications and failed to label Resident (R) 12 and R48 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when the pens expired. This deficient practice placed the affected residents at risk for ineffective medications.Findings included:- On 07/21/25 at 12:26 PM during the tour of the medication room on the 300 hall/unit, R48 and R12’s in use long-acting insulin (a hormone that lowers the level of glucose in the blood) pens (apparatus to inject the insulin) were stored in a cabinet with the blood sugar checking machines. Licensed Nurse (LN) HH stated the insulin pens in use for R48 and R12 should have a label to when the pens were put into use and when the pens would expire. On 07/23/25 at 10:45 AM, Administrative Nurse D verified the insulin pens should have been labeled with dates when put in use for the resident, along with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 84 residents. The sample included 27 residents, of whom one was reviewed for the provision of mental-related social services. Based on observation, record review, and interview, the facility failed to provide dental services to meet Resident (R) 37's, when she reported missing and loose teeth in her dentures. This placed the resident at risk for decreased quality of care and life.Findings included: - R37's Electronic Medical Record (EMR) documented R37 had a diagnosis of arthritis (inflammation of a joint characterized by pain, swelling, redness, and limitation of movement).R37's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R37 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R37 was independent with eating, had broken or loosely fitting full or partial dentures.R37's Care Plan, revised 07/03/25, documented R37 was edentulous and instructed staff to assess dentures for proper fitting, assist as needed…

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

The facility identified a census of 90 residents with three residents reviewed for activities of daily living (ADL). Based on observation, record review and interview, the facility failed to provide care per the resident's preferences and to promote dignity for Resident (R) 1, who required extensive staff assistance for dressing and hygiene which resulted in R1 exposed her breast in the dining room. This deficient practice placed R1 at risk for impaired dignity. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (high blood pressure). R1's Annual Minimum Data Set (MDS), dated 07/19/24, documented the Brief Interview for Mental Status could not be completed. The MDS documented R1 had short-term and long-term memory problems and had severe cognitive impairment. The MDS documented R1 had physical behavioral symptoms…

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 77 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 77 residents who resided in the facility and received their meals from the kitchen. Findings included: - On 11/27/23 at 09:05 AM, observation revealed dietary staff in the kitchen prepared the lunch meal of macaroni and cheese, broccoli, and chocolate peanut butter brownie. On 11/27/23 at 09:10 AM, Dietary Staff BB verified he worked at the facility for a few months. He said he was enrolled in a dietary manager course. Dietary Staff BB stated four residents received a pureed (foods with soft, pudding like consistency) diet. On 11/30/23 at 11:45 AM, Administrative Nurse D verified Dietary Staff BB was not certified and was currently enrolled in the dietary manager online course. The Facility's Director of Dining Services dated 5/2023 documented the day-to-day functions of the dining services department shall be under the supervision of Director of Dining Services,…

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 77 residents. Based on observation, record review, and interview, the facility failed to serve palatable food during meals that maintained appetizing temperatures and conserved nutritive values for the residents who resided in the facility and received food from the facility kitchen. This placed the residents at risk for decreased enjoyment of meals and increased risk for weight loss. Findings included: - The 11/27/23 lunch menu recorded tortellini with [NAME] sauce, fresh steamed broccoli, whole wheat dinner roll, and a peanut butter brownie. On 11/27/23 at 11:20 AM, observation during the noon meal revealed staff brought the insulated food cart to the 600-hall dining area. At 11:30 AM, staff uncovered the food on the steam table and obtained the following temperatures: Tortellini with cheese sauce was 161.7 degrees Fahrenheit (F) Broccoli was 171.7 degrees F. The broccoli was brown with no green visible; the broccoli was not readily identifiable as broccoli. An unidentified dietary staff said she obtained a temperature on broccoli and stated 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 77 residents. The sample included 19 residents. Based on record review and interview, the facility failed to complete comprehensive Minimum Data Set Assessment (MDS) for one sampled resident, Resident (R)31 and eight unsampled residents, R13, R17, R26, R30, R36, R39, R58, and R64. This placed the resident's at risk for unmet care needs and inaccurate assessments. Findings included: - R13's Electronic Medical Record (EMR) recorded a quarterly MDS, dated [DATE]. R13's EMR recorded a comprehensive MDS, dated [DATE], was in progress but not completed or submitted as required. R17's EMR recorded a comprehensive MDS, dated [DATE]. R17's EMR recorded a significant change MDS, dated [DATE], was in progress but not completed or submitted as required. R26's EMR recorded a quarterly MDS, dated [DATE]. R26's EMR recorded a comprehensive MDS, dated [DATE], was in progress but not completed or submitted as required. R30's EMR recorded a quarterly MDS, dated [DATE]. R30's EMR recorded 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 had a census of 77 residents. The sample included 19 residents. Based on record review and interview, the facility failed to conduct a quarterly Minimum Data Set (MDS) assessment in the required timeframe for five sampled residents: Resident (R)3, R10, R54, R65, and R180 and 16 unsampled residents: Resident (R)5, R7, R18, R19, R22, R23, R37, R38, R40, R41, R48, R57, R58, R60, R66, and R67. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - R3's Electronic Medical Record (EMR) recorded a comprehensive MDS, dated [DATE]. R3's EMR recorded a quarterly MDS, dated [DATE], was in progress but not completed or submitted as required. R5's EMR recorded a quarterly MDS dated , 07/17/23. R5's EMR recorded a quarterly MDS, dated [DATE], was in progress but not completed or submitted as required. R7's EMR recorded a quarterly MDS, dated [DATE]. R7's EMR recorded a quarterly MDS, dated [DATE], was in progress but not completed or submitted as required. R10'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - The Medical Diagnosis section of R3's Electronic Medical Record (EMR) included diagnoses of congested heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic respiratory failure with hypoxia (inadequate supply of oxygen), urinary tract infection (UTI-an infection in any part of the urinary system), chronic kidney disease, retention of urine, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Comprehensive Minimum Data Set (MDS), dated [DATE], documented R3 had moderately impaired cognition, was dependent on staff for oral hygiene, toileting hygiene, and dressing. R3 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. The MDS further documented R3 had pain and received scheduled and as needed pain medication. R3 took an anticoagulant (a group of medication that decreases blood ability to clot), antibiotic (medication used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care for Resident (R) 14 who was prescribed an anticoagulant (a group of medication that decreases blood ability to clot) which placed the resident at risk for uncommunicated care needs. Finding included: - The Medical Diagnosis section of R14's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), encounter for orthopedic (pertaining to bones) aftercare, fracture (broken bone) of around internal prosthesis (artificial body part) of left hip, pulmonary fibrosis (scaring of the lungs), atrial fibrillation (rapid, irregular heart beat), muscle weakness, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Comprehensive Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sampled included 19 residents, with five reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered interventions for dementia related behaviors for two sampled residents, Resident (R) 34 and R180. This placed the resident's at risk for abuse and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R34 had diagnoses of dementia without behaviors, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission Minimum Data Set (MDS), dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sample included 19 residents, with six reviewed for bowel/bladder incontinence, indwelling catheter (tube placed in the bladder to drain urine into a collection bad), and urinary tract infections (UTI). Based on observation, record review, and interview, the facility failed to provide Resident (R) 28, R180, and R3 with appropriate catheter care which placed the residents at risk for infection. Findings included: - R28's Care Plan, dated 09/14/23, initiated on 03/16/23, directed staff to monitor for signs and symptoms of a UTI, and directed staff to maintain a closed drainage system per facility protocol; secure the catheter to R28's leg to avoid tension on urinary meatus; assess for adequate output, color, and odor of urine. The plan documented R28 had potential for reoccurrence of UTIs and directed staff to assess, record, and report to physician any signs and symptoms of a UTI. The plan directed staff to obtain and monitor lab work as order, assist with perineal…

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 77 residents. The sample included 19 residents, with five reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R) 34 and R180, who had dementia and behaviors, and failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for R180. This placed the residents at risk for abuse and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R34 had diagnoses of dementia without behaviors, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and depression…

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 77 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a 14-day stop date for Resident (R)12's as needed (PRN) lorazepam (Ativan-medication used to treat anxiety) and failed to identify and report the lack an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the use of an antipsychotic for R6 and R65. This placed the affected residents at risk for unintended affects related to psychotropic (affects mind or thoughts) drug medications. Findings included: - R12's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental, uncertainty and irrational fear), and chronic respiratory failure. R12's Significant Change Minimum Data Set (MDS), dated [DATE], 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 77 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to ensure a 14-day stop date for Resident (R)12's as needed (PRN) lorazepam (Ativan-medication used to treat anxiety). The facility further failed to ensure R6 and R65 had an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the use of an antipsychotic. This placed the affected residents at risk for unintended affects related to psychotropic (affects mind or thoughts) drug medications. Findings included: - R12's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental, uncertainty and irrational fear), and chronic respiratory failure. R12's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. R12 required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to prevent a significant medication error for Resident (R) 34, whose Zyprexa (an antipsychotic medication) was not given for two days. The facility further failed to prevent medication errors when staff crushed three medications for R52 that were supposed to be given whole. This placed the residents at risk for decreased well-being and ineffective medication regimen. Findings included: - R34's Electronic Medical Record (EMR) documented R34 had diagnoses of dementia without behaviors, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)53's outdated insulin (hormone which allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 10:10AM, observation revealed R53's Novolog (rapid acting insulin) flex pen had an open date of [DATE] (149 days) and lacked a discard date. On [DATE] at 10:10 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the insulin pen when expired. On [DATE] at 01:30 PM, Administrative Nurse D verified the nurses should label and date the flex pens with the resident's name and discard expired and/or outdated pens. According to www.Medlineplus.gov, Novolog pens can be used within 28 days, but after that time they must be discarded. The facility's Storage of Medications policy, 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.

The facility had a census of 77 residents. The sample included 19 residents, with six reviewed for indwelling catheter (tube placed in the bladder to drain urine into a collection bad), and urinary tract infections (UTI). Based on observation, record review, and interview, the facility failed to use acceptable infection control practices related to caring for indwelling catheters for three residents. This placed the residents at increased risk for infectious disease. Findings included: - On 11/28/23 at 12:18 PM, observation revealed Certified Nurse Aide (CNA) P removed Resident (R)28's catheter bag from the dignity bag and proceeded to drain the urine from the catheter bag into a container. CNA P then reattached the drainage port to the bag and threw the catheter bag onto the floor. On 11/29/23 at 09:28 AM, observation revealed R3 remained in bed. The catheter drainage bag was hooked to the bed frame at the foot of the bed, did not have a privacy bag, and touched the floor. It was visible from the hallway. On 11/29/23 at 10:03 AM, observation revealed CNA M assisted R3 with ADLs.…

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 73 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for eight residents who received pureed diets placing the residents at risk for inadequate nutrition. Findings included: - On 06/02/22 at 12:07 PM, observation revealed Dietary Staff (DS) CC prepared pureed meals for eight residents. DS CC placed eight servings of fried chicken nuggets into a blender, then added milk from a gallon jug, then blended the fried chicken nuggets until desired consistency. DS CC repeated the same procedure with eight eggrolls, adding milk until desired consistency. On 06/07/22 at 07:30 AM, DS CC stated she was aware of pureed recipes. DS CC verified she had used milk to blend the fried chicken nuggets and eggrolls. She stated she used milk because it was faster when staff were busy in the kitchen. On 06/07/22 at 10:42 AM, Consultant Staff…

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

The facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff left uncovered, unattended clean laundry in a container in the hall, provided poor hand hygiene during cares, carried a trash bag from another hall onto the 500 hall, which contained positive COVID-19 (highly contagious, potentially fatal respiratory infection) residents without placing full personal protective equipment (PPE) prior to entering. Staff entered Resident (R) 27, R53, and R37's (on Covid-19 isolation precautions) rooms without placing full PPE on and failed to disinfectant a vitals machine (used to check body temperature, pulse rate, respiration rateand blood pressure between residents. This placed the residents at risk for infection. Findings included: - On 06/01/22 at 09:04 AM, observation revealed the 500 hall doors closed. An isolation cart was outside the door which…

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 73 residents. The sample included 18 residents of which one reviewed for dignity. Based on observation, record review, and interview, the facility failed to treat Resident (R) 24 with dignity promoting her quality of life by not cleaning R24's soft neck collar which contained food particles from meals. This placed R24 at risk for impaired dignity and decreased psychosocial wellbeing. Findings included: - R24's Electronic Medical Record (EMR) documented she had a diagnosis of cervical fracture (broken bone in the neck). R24's Annual Minimal Data Set (MDS), dated [DATE], indicated R24 had short- and long-term memory problems, and moderately impaired cognition. The MDS documented the resident required extensive staff assistance with eating and personal hygiene. R24's Activities of Daily Living Care Plan, updated 05/10/22, informed the staff to wash R24's face after meals. It directed R24 to wear a soft neck collar at all times. On 06/01/22 at 12:10 PM, observation revealed R24 sat 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 73 residents. The sample included 18 residents. with two residents reviewed for hydration, Resident (R) 3 and R16, who were on a fluid restriction (the amount of fluid required each day). The facility failed to review or revise the care plan for concise direction for staff regarding the fluid restriction. This placed the residents at risk for inadequate care. Findings Included: - R3's Electronic Medical Record (EMR) documented she had diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and edema (excess fluid tramped in the body's tissues). R3's Quarterly Minimum 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 on the unit, extensive staff assistance with bed mobility, and required only set up for meals. R3's Nutrition Care Plan, updated on 05/20/22, informed 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 73 residents. The sample included 18 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of two residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 71. This placed the resident at risk for receiving inadequate care. Findings included: - R71's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated 04/11/22, documented the resident had a Brief Interview of Mental Status score of 15, which indicated intact cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, walk in corridor and room, locomotion on and off unit, toilet use, limited staff assistance with personal hygiene, and supervision with eating. The MDS documented R71 expected to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 73 residents. The sample included 18 residents with seven reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services and offer alternative bathing interventions for two sampled residents, Resident (R) 16, and R66. This placed the residents at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) recorded R16 had diagnoses of chronic kidney disease stage three (mild to moderate kidney damage), atrial fibrillation (irregular heart rate), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated , 03/10/22, documented R16 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, toileting, and limited assistance of one staff for personal hygiene. The MDS further documented R16 was dependent on two staff assistance for bathing. The ADL Care Plan, dated 04/14/22, 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 73 residents. The sample included 18 residents, with one reviewed for activities. Based on observation, record review, and interview, the facility failed to provide activities for one resident, Resident (R) 66, who had dementia, placing the resident at risk for decreased social interaction and boredom. Findings included: - The Electronic Medical Record (EMR) documented R66 had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), psychosis (any major mental disorder characterized by a gross impairment in reality testing), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R66 had severely impaired cognition and required extensive assistance of two staff for bed mobility,…

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 73 residents. The sample included 18 residents. with two residents reviewed for hydration, Resident (R) 3 and R16, who were on a fluid restriction (the amount of fluid required each day). The facility failed to monitor adequate hydration for R3 and R6. This placed the resident at risk for fluid overload or dehydration. Findings Included: - R3's Electronic Medical Record (EMR) documented she had diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and edema (excess fluid tramped in the body's tissues). R3's Quarterly Minimum 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 on the unit, extensive staff assistance with bed mobility, and required only set up for meals. R3's Nutrition Care Plan, updated on 05/20/22, informed the staff the resident had a potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 73 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 55's bowel movements which placed the resident at risk for complications related to constipation (difficulty passing stools). Findings included: - R55's Physician Order Sheet documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), age related debility, abdominal pain and gastritis) inflammation of the stomach lining). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R55 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.

The facility had a census of 76 residents. The facility identified six medications rooms. Based on observation, record review , and interview the facility failed to label two insulin (medication used to regulate the level of sugar (glucose) in the blood) kwik pens (a device used to inject insulin) with the date opened in one of three medication rooms. This placed the residents at risk for ineffective medication. Findings included: - On 06/01/22 at 11:09 AM, observation in Victorian neighborhood (300 hall) medication room refrigerator revealed R32's open Tresiba (long-acting insulin) kwik pen and her open Humalog (fast-acting insulin) kwikpen without a date indicating when they were opened. On 06/01/22 at 11:09 AM, Licensed Nurse (LN) J verified the above observation and stated staff should date all insulin kwikpens when they open them. On 06/07/22 at 11:43 AM PM, Administrative Nurse D stated staff should date and label insulin pens when they opened it. The facility's Administering Medications Policy, revised 12/21, documented when opening a multi-dose container, the date opened…

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.