Diversicare Of Haysville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 81 residents. The sample included 21 residents, with four reviewed for accommodation of needs. Based on interviews, observations, and record review, the facility failed to ensure Resident (R) 3 and R66 had the appropriate call light or other method to communicate their needs. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - The Medical Diagnosis section within R3's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), muscle weakness, need for assistance with care, intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), and obesity (severely overweight). R3's Quarterly Minimum Data Set (MDS) dated 11/29/25 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted she used a wheelchair for mobility. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample includes 21 residents, with five residents reviewed for resident funds. Based on observation, record review, and interviews, the facility failed to provide and or ensure resident funds accounts were accessible 24 hours a day seven days a week. This deficient practice placed residents at risk for decreased psychosocial well-being. Findings Included: - On [DATE] at 10:13 AM, Resident Council members Resident (R) 19, R53, and R65 reported the only way residents could access their money in their trust accounts was through Administrative Staff B. They reported that they were only aware that money withdrawals occurred Monday through Friday from 11:00 AM to 12:00 PM during the day. She stated we set a time because residents would be in my office all day long. On [DATE] at 11:431AM, Certified Medication Aide (CMA) R stated residents can get money on the weekends, she stated there was money in an envelope on the 300-hall cart. CMA R stated residents could ask…

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 81 residents. The sample included 21 residents, with one reviewed for abuse and/or neglect. Based on record review and interview, the facility failed to ensure Resident (R) 35 was free from abuse when R35's medication was misappropriated from the facility medication cart. This placed the residents at risk for both physical and psychosocial negative outcomes. Findings included: - R35's Electronic Medical Record (EMR) under the Diagnosis tab recorded diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) of the left nondominant side, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of ten which indicated moderately…

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 81 residents. The sample included 21 residents, with one reviewed for abuse and/or neglect. Based on record review and interview, the facility failed to submit a full investigation of a reportable occurrence for Resident (R) 35 to the appropriate state agency within twenty-four hours as required for misappropriation of R35's missing controlled substance. This placed the residents at risk for unidentified and ongoing abuse and /or neglect. Findings included: - R35's Electronic Medical Record (EMR) under the Diagnosis tab recorded diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) of the left nondominant side, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents, with three sampled residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 14 and R54 and their representative received written notification of transfer, as soon as practicable to R14 and R54 or their representative for their facility-initiated transfer. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R14 and R54. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs), diabetes mellitus (DM - when…

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 81 residents. The sample included 21 residents, with three sampled residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a bed hold policy to Resident (R) 14 and R54 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability for R14 and R54 to return to the facility and their previous rooms. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), bipolar disorder (a major mental…

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

The facility identified a census of 81 residents. The sample included 21 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities on Sundays to promote socialization. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings included: - A review of the facility's Activity Calendar for January, February, and March 2025 was completed. The Activity Calendar for January 2025 recorded each Sunday listed church services at 02:00 PM. The Activity Calendar for February 2025 recorded each Sunday listed church services at 2:00 PM, Sunday 02/02/25 at 06:30 PM listed resident movie night, 02/09/25 at 06:30 PM listed game night, 02/16/25 at 06:30 listed resident chooses game night, and 02/23/25 at 06:30 listed resident movie night. The Activities Calendar for March 2025 recorded each Sunday listed church services at 02:00 PM, Sunday 03/02/25 at 06:30 PM listed residents choose a game to play, on 03/09/25 at 06:30 PM card games, on 03/16/25 at 0:6:30 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) for Resident (R) 2. This deficient practice placed R2 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), CHF, and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact…

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 81 residents. The sample included 21 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 12 to promote the resident's highest practicable level of well-being. This deficient practice placed R12 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), insomnia (difficulty sleeping), and need for assistance with personal cares. R12's Annual Minimum Data Set (MDS) dated 02/14/25 noted a Brief Interview for Mental Status (BIMS) score of six indicating…

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 81 residents. The sample included 21 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for Resident (R) 61's as needed psychotropic medication (alters mood or thought). The facility also failed to ensure the CP identified and reported irregularities regarding lack of dosing instructions for Voltaren (topical pain reliever medication) gel and the lack of monitoring antihypertensive (a class of medication used to treat high blood pressure) medications for R54. The facility also failed to ensure the CP identified and reported irregularities regarding lack of documentation of R14's oxygen saturation monitoring. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications. Findings included: - R61's Electronic Medical Record (EMR) from the…

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

The facility identified a census of 81 residents. The sample included 21 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 14's oxygen (O2) saturation was monitored and documented as physician ordered. The facility failed to ensure staff monitored and documented R54's pulse for her antiarrhythmic (medications used to treat abnormal heart rhythms) and R54's blood pressure for her beta blocker (a medication used to treat high blood pressure and other cardiac conditions). This deficient practice placed these residents at risk for unnecessary medication administration and related complications. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart is unable to pump enough…

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 81 residents. The sample included 21 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the as needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 61's PRN psychotropic medications. This placed R61 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - R61's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview…

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 81 residents. The sample included 21 residents, with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 32. The facility also failed to administer PCV20 for R54 who had given consent. This placed these residents at increased risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease. Findings included: - Review of R32's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R54's clinical record revealed the PCV13 was administered on 11/15/20. The facility provided a signed consent for PCV20 dated 10/02/24. R54's clinical record lacked documentation PCV20 was administered. On 03/12/25 at 12:42 PM,…

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

The facility reported a census of 88 residents. Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in the resident rooms, shower rooms, and hallways, for all of the residents of the facility. Findings included: - On 10/10/23 at 10:09 AM an environmental tour revealed the following concerns on the 400 Hallway: 1. The fire door has multiple areas of scraped paint, with the largest area approximately one foot in width. 2. A resident room with scraped paint along the doorways, a dark substance around the base of the toilet, scraped paint on several walls, brown splatters on a wall, a brown substance on the handrail above the wall with the same splatter opposite of the toilet, peeling paint above the sink caulking, a bent floor vent with rust spots, floor tile with approximately a three inch area missing, and a paint scrape below and left of the windowsill. 3. A resident bathroom with a large area of rust colored stain around the sink drain, paint scrapes on the…

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

The facility reported a census of 88 residents. The 13 residents sampled included eight residents reviewed for resident funds. Based on observation, record review, and interview, the facility failed to safeguard cash in the facility safe located in the business office, for two of the eight residents reviewed resulting in theft of cash for R6 in the amount of $2,300 and for R7 in the amount of $4,000. The facility replaced the missing cash for these two residents but this practice left any other resident who placed cash or valuables in the facility safe at potential for loss. Findings included: - The facility investigation dated 10/09/23 revealed on 10/03/23 at approximately 02:00 PM, Administrative Staff B noted cash funds missing from the facility safe in the total amount of $6,300. Administrative Staff B then notified Consultant Staff HH, who arrived at the facility, completed a search of the safe, and confirmed the funds were missing. R6 and R7 had previously placed funds in the total amount of $6,300 in the safe. The staff notified the local law enforcement who arrived, took…

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

The facility reported a census of 88 residents with 13 selected for review, including five residents reviewed for personal funds accounts, Resident (R)9, R10, R11, R12, and R13. Based on record review and interview, the facility failed to provide notification to the five selected residents, who received Medicaid benefits, when the amount in their trust account reached $200.00 less than the SSI (Supplemental Security Income) resource limit (Limit is $2,000) to prevent loss of eligibility for Medicaid or SSI. Findings included: - The Midnight Census Report dated 10/08/23 revealed the Primary Payor source for R9 was Hospice Medicaid, and Primary Payor source was only Medicaid for R10, R11, R12, and R13. The Resident Statement Landscape for R9 revealed from 01/03/23 through 09/11/23 his account balance ranged from $7,891.90 to $11,231.60. The Resident Statement Landscape for R10 revealed from 07/28/23 through 09/06/23 her balance ranged from $3,781.57 to $5,605.85. The Resident Statement Landscape for R11 revealed from 01/03/23 through 09/06/23 his balance ranged from $6,207.80 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.

The facility reported a census of 87 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an environmental tour of the kitchen on 05/17/23 at 07:03 AM, with dietary staff N and O, revealed the following areas of concern: 1. There was a loose hose on the top of the ice machine. No staff member was aware of what the hose led to. 2. The juice machine had a build-up of sticky, dried juice on the nozzle. 3. The large, industrial can opener had a build-up of dried food on the tip. 4. The drain to the ice machine lacked a two-inch air gap to prevent backflow into the ice. 5. Thirteen cookie sheets contained a sticky, dried on substance over the cooking area of the pan. 6. The metal dish rack used to hold individual serving bowls, had rust in multiple areas of the rack. 7. The metal rack used to hold pots and pans had a sticky substance on multiple areas of the rack. 8. Four skillets…

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

The facility reported a census of 87 residents. Based on observation, record review and interview, the facility failed to provide necessary maintenance services for the kitchen floor to provide a safe, functional and sanitary environment. Findings included: - During an environmental tour of the kitchen on 05/17/23 at 07:03 AM, revealed the following concern: The kitchen floor had multiple cracked, broken tiles throughout the kitchen. On 05/17/23 at 07:03 AM, Dietary staff O confirmed the kitchen floor had multiple broken tiles. The facility lacked a policy for the upkeep of the kitchen floor. The facility failed to provide necessary maintenance services for the kitchen floor to provide a safe, functional and sanitary environment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 87 residents with 18 residents included in the sample. Based on observation, interview, and record review the facility failed to review and revise care plans for four sampled residents including, interventions to prevent further falls for Resident (R)73, behaviors for the use of an antipsychotic medication for R29, with instructions for the dialysis communication sheet for R72, and for Activities of Daily Living needs of R3. Findings included: - R73's Electronic Medical Record (EMR) revealed the following diagnoses: chronic kidney disease, (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), hip fracture (broken bone), Pelvic fracture, acute respiratory failure, (inability to breathe), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The resident…

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 census totaled 87 residents with 26 residents residing one hall, and one bath house used to bathe those 26 residents. Based on observation, interview, and record review the facility failed to ensure call light accessibility to these 26 residents when they received showers in this one shower room. The shower area lacked a cord on the two call lights located in the shower and the call light next to the toilet making them inaccessible to residents receiving showers and staff providing showers, in case of emergency. Findings included: - Tour of the facility on 05/15/23, revealed a shower room on one of the resident halls. Observation of the room for functional call lights, revealed the two call lights in the shower area lacked pull cords attached for residents or staff to use in case of an emergency. Additionally, the call light in the same room but next to the toilet also lacked a pull cord attached for residents or staff to use in case of an emergency. On 05/15/23 at 11:05 AM, Certified Nurse Aide (CNA) S stated that the call lights in the shower room should have pull…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 87 residents with 18 residents sampled, including three residents reviewed for dignity. Based on observation, interview and record review, the facility failed to treat two residents with respect and dignity including Resident (R)3, by leaving the resident exposed to others in the hallway while she rested in bed and (R) 29, wearing soiled clothing. Findings included: - Review of Resident (R)3's electronic medical record (EMR) included a diagnosis of weakness. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She required extensive assistance of two staff for bed mobility and extensive assistance of one staff for dressing. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/18/23, documented the resident was alert with confusion and required extensive assistance of one to two staff for most daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 87 residents with 18 included in the sample including one reviewed for hospitalization. Based on interview and record review the facility failed to provide a copy of the facility bed hold policy to Resident (R) 73 or his representative with hospital transfer. Findings included: - Review of R73 Minimum Data Set tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R73's Electronic Medical Record revealed it lacked evidence of written notification of the facility-initiated hospitalization transfer and bed hold to the resident or to her representative. On 05/16/23 at 07:20 AM, Certified Nursing Assistant (CNA) P performed AM care to the resident as she sat in her wheelchair. The sit to stand lift sat in the room and staff reported she just transferred the resident to her chair with just one staff herself. The resident was alert with no signs of distress or discomfort. On 05/17/23 at 8:40 AM, Administrative Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 87 residents with 18 residents sampled. Based on interview and record review, the facility failed to complete a individualized comprehensive care plan for one Resident (R)3, regarding the use of oxygen. Findings included: - Review of Resident (R)3's electronic medical record (EMR), included a diagnosis of respiratory failure (the inability of the lungs to perform their basic task of gas exchange, the transfer of oxygen from inhaled air into the blood and the transfer of carbon dioxide from the blood into exhaled air). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The resident used oxygen while a resident. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/18/23, documented the resident had a diagnosis of sleep apnea (sleep disorder characterized by periods without respirations). 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 census totaled 86 residents with 18 included in the sample. Based on observation, interview, and record review the facility failed to ensure planned and implemented interventions following a fall by one sampled resident (R) 73, to prevent further falls and potential injury. Findings included: - R73's Electronic Medical Record (EMR) revealed the following diagnoses: chronic kidney disease, (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), hip fracture (broken bone), Pelvic fracture, acute respiratory failure, (inability to breathe), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The resident required extensive assistance of two staff for transfers, was non-ambulatory, and required extensive assistance of one for dressing and toileting. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 87 residents with 18 residents sampled, including three residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to appropriately administer oxygen to Resident (R)138 as ordered. In addition, the facility failed to properly store the nebulizer (a device for administering inhaled medications) and to correctly store distilled water used for oxygen humidification for R78. These deficient practices could lead to possible respiratory complications and/or infections. Findings included: - R78's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute sudden and chronic (persisting for a long period) respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 87 residents with 18 residents sampled, including one resident reviewed for dialysis. Based on observation, interview, and record review, the facility failed to ensure appropriate adequate communication between the dialysis center and the facility, for the one Resident (R)72, regarding a lack of regular dialysis communication sheets, with the facility. Findings included: - Review of Resident (R)72's electronic medical record (EMR), included a diagnosis of end stage renal disease (condition where the kidney reaches advanced state of loss of function). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She was independent with activities of daily living (ADL) and received dialysis (when a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body). The Care Area Assessment, dated 09/27/22, lacked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 87 residents with 18 residents in the sample which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure two of the five sampled residents, including Resident (R) 8 and R18 were appropriately and timely monitored for side effects of extrapyramidal (abnormal involuntary body movements caused by medications) symptoms due to antipsychotic (a class of medication used to treat psychosis and other mental emotional conditions) medication use. Findings included: - R8's pertinent diagnoses from the Electronic Health Record (EHR) documented schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), major depressive disorder (MDD - a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 87 residents with 18 residents included in the sample. Based on observation, interview, and record review the facility failed to honor Resident (R) 14's dietary food choices when the resident requested no pork be served and the facility continued to serve her pork. Findings included: - R14's signed physician orders dated 03/10/23, revealed hypertension (elevated blood pressure), hypothyroidism (condition characterized by decreased activity of the thyroid gland) diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and the resident had no reported behavior issues. Review of the Care Plan dated 03/13/23, revealed it instructed the staff to serve the resident's diet as ordered. The Registered Dietician was to evaluate and make diet change recommendation as…

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.

- Resident (R) 78's diagnoses from the Electronic Health Record (EHR) included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) acute (sudden) and chronic (persisting for a long period) and respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest). The 03/08/23 admission Minimum Data Set (MDS) documented brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident required limited or extensive assistance of one staff for most cares and received the use of oxygen (O2). The 04/29/23 quarterly MDS documented a BIMS of 12, indicating moderately impaired cognition and the resident continued to receive oxygen. The 03/08/23 Care Area Assessment (CAA) lacked documentation related to the oxygen usage. R78's EHR Physician Orders included ipratropium-albuterol inhalation solution to be given three times per day for shortness of air but…

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 census totaled 78 residents with 18 in the sample. Based on observation, interview, and record review the facility failed to ensure a sanitary environment when Certified Nurse Aide (CNA) staff did not change gloves and perform hand hygiene when going from dirty to clean areas, during two observation of incontinence care for Resident (R) 44. Findings included: - Observation on 10/11/21 at 09:52 AM revealed Certified Nurse Aide (CNA) O and CNA N prepared to change the R44's brief. CNA O and CNA N washed their hands and donned (put on) gloves. CNA N removed the residents wet brief, placed a clean brief under the resident, and then used wet wipes to provide peri-care to the resident. CNA N used the wet wipes to clean the front of the resident but did not clean between R44's legs or buttocks. CNA N fastened the adhesive tabs on R44's clean brief. CNA N wore the same gloves throughout the observation of R44's brief change and peri-care. Observation on 10/12/21 at 11:15 AM CNA P and CNA M donned gloves then moved the R44's bed. CNA M peeled the adhesive tabs back from R44'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.