Life Care Center Of Kansas City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 57 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of monitoring antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R10. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of adult failure to thrive, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 57 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow the pharmacist's recommendation for the monitoring of antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R10. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of adult failure to thrive, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated 04/21/25 documented a Brief Interview of 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 57 residents. The sample included 14 residents, with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections), and pneumococcal (type of bacterial infection) vaccination for Resident (R) 1, R7, and R29. This placed the residents at increased risk for complications related to pneumonia. Findings included:- Review of R1's clinical record revealed the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined on 09/13/24. R2's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R7's clinical record revealed the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined on 10/07/24. R7's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of 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 reported a census of 66 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exited the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent R1 from exiting the facility. This placed R1 at risk for accidents or injuries. Findings include: - R1's Electronic Medical Record (EMR), under the Diagnosis tab documented diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), muscle weakness, abnormalities of gait and mobility, convulsions (involuntary series of contractions of a group of muscles), hypertension (elevated blood pressure), hypotension (low blood pressure), dizziness, and anxiety (mental or emotional reaction characterized by apprehension,…

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 63 residents. The sample included four residents. Based on observation, interview, and record review, the facility failed to accurately and thoroughly complete Minimum Data Sets (MDS) for Resident (R) 1. This placed the resident at risk for unidentified care needs. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), convulsions (involuntary series of contractions of a group of muscles), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual MDS dated 05/17/23 documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. R1 was independent with activities of daily living (ADL). R1's oral and dental status documented there were no dental concerns noted. The Dental Care Area Assessment…

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 63 residents. The sample included three residents reviewed for dental services. Based on record review, interview, and observation, the facility failed to identify and respond to Resident (R)1's dental needs which resulted in tooth pain and untreated dental issues. This deficient practice placed R1 at risk for pain and other complications related to dental issues. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), convulsions (involuntary series of contractions of a group of muscles), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 69 residents. The sample included three residents. Based on record review, interview, and observation the facility failed to accommodate Resident (R) 1's need and preference for a transfer pole This placed R1 at risk of decreased mobility and impaired autonomy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of hemiplegia (paralysis of one side of the body), 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), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), muscle weakness, need for assistance with personal care, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R1's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of…

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

The facility identified a census of 67 residents. The sample included 17 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This placed the residents at risk for decreased quality of care. Findings included: - Review of the Payroll-Based Journal for Fiscal Year 2023 Quarters1 through 4 revealed the facility triggered for no RN hours on four or more weekend days during quarter one 10/15/22, 10/16/22, 10/22/22, 10/29/22, 10/30/22,11/05/22, 11/12/22, 11/13/22, 11/19/22, 11/26/22,12/03/22, 12/10/22, 12/11/22, and 12/24/22). Review of the Payroll-Based Journal for Fiscal Year 2023 Quarter2 revealed the facility triggered for no RN hours on four or more weekend days during the quarter (01/01/23, 01/15/23, 01/21/23, 02/04/23, 02/05/23, 02/12/23, 02/18/23, 02/19/23, 02/26/23, 03/12/23, 03/18/23, and 03/26/23). Upon request, the facility provided handwritten Time Clock Adjustment sheets for the dates listed above. The facility failed to provide proof of eight hours of…

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

The facility identified a census of 67 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns. Findings included: On 01/02/24 at 07:27 AM an observation in the main kitchen area revealed three plastic storage containers with cereal inside. The containers lacked labels and were undated. On 01/02/24 at 07:35 AM an observation in the kitchen's meat freezer revealed two resealable plastic bags. One plastic bag contained ham and the other contained chicken patties. The plastic bags were not labeled and were undated. On 01/02/24 at 07:36 AM, an observation in the kitchen's meat freezer revealed one opened box of frozen beef patties. The box was open to air and the patties were uncovered. On 01/02/24 at 07:38 AM, an observation in the kitchen's dry storage area revealed one bag of dry noodles. The bag was opened and was undated. On 01/02/24 at 07:39 AM, an…

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

The facility identified a census of 67 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens, failed to ensure sanitary storage of respiratory equipment, failed to ensure adequate laundry temperatures for laundry including laundry from residents with infectious disease and on transmission-based precautions and failed to ensure staff performed hand hygiene between resident car. The facility further failed to ensure appropriate disposal of filled red biohazard boxes and failed to ensure the Infection Preventionist tracked and trended infections within the facility. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 01/02/24 at 07:05 AM a large bag of soiled linen rested on the floor in the 200 hallways.…

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 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from January 2023 through December 2023, lacked evidence of organism identifications, duration of antibiotic prescribed, and the infections treated. The facility was unable to provide evidence of tracking upon request. On 01/04/23 at 10:39 AM Administrative Nurse E, the facility Infection Preventionist stated she had a book that she did track the facility's infections some place. Administrative Nurse E stated she completed Mcgeer's criteria after a urine analysis was obtained. The facility's Antibiotic Stewardship policy last reviewed on 05/19/23 documented that the antibiotic stewardship program promoted the appropriate use of antibiotics…

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 67 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure the residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings included: - Upon the initial tour of the building on 01/02/24 at 07:05 AM and walkthrough of the facility revealed a heavy urine smell throughout the facility. On 01/02/24 at 12:44 PM room [ROOM NUMBER] bathroom had no mirror on the wall and the paper towel dispenser was missing a cover. On 01/02/24 at 12:47 PM, the wall behind bed A in room [ROOM NUMBER] was torn up and missing paint. On 01/02/24 at 12:50 PM, room [ROOM NUMBER] was missing a plaque on the wall that showed the room number. On 01/02/24 at 01:00 PM the couch in the 100 hall tv area had an unattended cup with clear liquid in it sitting on the cushion. On 01/03/24 at…

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 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being and boredom. Findings included: - A review of the facility's Activity Calendars for October, November, and December of 2023 was completed. The review revealed Resident's Choice was the only facility-led activity on the weekends for all three months. A review of the weekday activity calendar revealed Bingo, games time, social events, manicures, and sports events. On 01/03/24 at 02:00 PM, the facility held a staff-led Bingo game in the main dining area. The game included resident involvement from both (South and North) halls. The game included snacks and prizes provided to the residents. On 01/03/24 at 01:15 PM, Resident Council members reported the weekend lacked consistent activities since the facility's Activities Coordinator left in November 2023. The council reported some of the direct…

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 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional. This placed the affected residents at risk for decreased quality of life. Findings included: - A review of the facility's Activity Calendars for October, November, and December of 2023 was completed. The review revealed Resident's Choice was the only facility-led activity on the weekends for all three months. A review of the weekday activity calendar revealed Bingo, games time, social events, manicures, and sports events. On 01/03/24 at 02:00 PM, the facility held a staff-led Bingo game in the main dining area. The game included resident involvement from both (South and North) halls. The game included snacks and prizes provided to the residents. On 01/03/24 at 01:15 PM, Resident Council members reported the weekend lacked consistent activities since the facility's Activities Coordinator left in November 2023. The council reported some of the direct care staff tried to hold…

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 67 residents. The sample included 17 residents with one resident reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure hazardous materials when the facility failed to ensure a Sharps container (bin to place used needles and lancets) mounted on the side of a cart and stored in the hallway had a lid to prevent residents from reaching into the container. This deficient practice placed the 19 cognitively impaired independently mobile residents at risk for preventable injuries and accidents. The facility additionally failed to ensure R53's portable urinal was within reach resulting in a non-injury fall. This deficient practice placed R53 at risk for preventable falls and injuries. Findings Included: - On 01/02/24 at 07:30 AM a walkthrough of the facility's 200 Hallway revealed a treatment cart next to the nurse's station. An inspection of the cart revealed a mounted Sharps container on the side of the cart. The Sharps…

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 67 residents. The Facility had four medication carts and two medication rooms. Based on observations, record reviews, and interviews, the facility failed to ensure the safe storage and handling of Resident (R)55's insulin medication (a hormone that lowers the level of glucose in the blood). This deficient practice placed the resident at risk for diversion and ineffective medication regimen. Findings Included: - On 01/02/24 at 07:35 AM a walkthrough of the facility's South Hall revealed a treatment cart by the nurse's station. An inspection of the treatment cart revealed unsecured insulin medication stored in plastic bins on top of the cart. The plastic bins contained four insulin glargine (long-acting insulin medication) auto-injector pens that belonged to R55. At 07:38 AM Licensed Nurse (LN) G stated she just left the area briefly to put her coat up. LN G stated the insulin should be supervised or locked up when not in use. She secured the insulin in the third drawer of her treatment cart. On 01/04/24 at 01:10 PM Administrative Nurse D stated…

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 67 residents. The sample included 17 residents with two reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Residents (R) R13 and R24 were treated in a dignified manner. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings included: - On 01/02/24 at 10:22 AM, observation revealed R13 laid on her back, in her bed, on top of her blankets. R13 wore a top that did not fully cover her abdomen and she wore an adult incontinence brief. R13 was uncovered and her brief and bare legs were exposed and visible from the hallway. R13 stared off to her right and did not respond to questions. On 01/02/24 at 12:12 PM, an observation revealed the door to R24's room was open, and a strong urine odor was detected in her room. R24 was observed in bed, uncovered, with her pants down around her knees and she wore an adult incontinence brief. R24 was visible from the hallway. On 01/04/24 at 11:36 Certified Nurse Aide (CNA) M stated if a resident was in a brief, uncovered,…

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 67 residents. The sample included 17 residents with two reviewed for accommodation of needs-related activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to identify and correct environmental challenges to Resident (R) 42's mobility. The facility additionally failed to provide R65 a call light in his room. This deficient practice placed both residents at risk for a decline in ADLs. Findings included: - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), major depressive disorder (major mood disorder), morbid obesity (severely overweight), sleep apnea (a disorder of sleep characterized by periods without respirations), and coronary atherosclerosis (mineral build-up on the walls of the heart's blood vessels). R42's Quarterly Minimum Data Set (MDS) completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.…

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 67 residents. The sample included 17 residents with five residents reviewed for nutrition. Based on record review, interviews, and observations, the facility failed to notify Resident (R)13's physician and representative regarding a weight loss and/or change in health condition. This placed R13 at risk for continued weight loss and malnutrition due to delayed physician and representative involvement. Findings included: - R13's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of legal blindness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The admission Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) assessment was unable to be completed. The MDS documented R13 had problems with recall ability and short-term and long-term memory. The MDS further documented R13 had severely impaired decision-making ability…

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 67 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide written notification to the long-term care ombudsman (LTCO) for Resident (R) 28 and R6. The facility failed to provide notice of transfer as soon as practicable to R6 or their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R28 and R6. Findings included: - The electronic medical record (EMR) for R28 documented diagnosis of hypertension (elevated blood pressure), chronic respiratory failure (when not enough oxygen passes from the lungs to the blood), and bradycardia (low heart rate, less than 60 beats per minute). The Annual Minimum Data Set (MDS) for R28 dated 07/03/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R28 was independent to limited assistance for activities…

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

The facility identified a census of 67 residents. The sample included 17 residents with 17 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)42's care plan to reflect the use of his personal knee braces. This deficient practice placed R42 at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), major depressive disorder (major mood disorder), morbid obesity (severely overweight), sleep apnea (a disorder of sleep characterized by periods without respirations), and coronary atherosclerosis (mineral build-up on the walls of the heart's blood vessels). R42's Quarterly Minimum Data Set (MDS) completed 12/14/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted he was independent with bed mobility, toileting, dressing, personal hygiene,…

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

The facility identified a census of 67 residents. The sample included 17 residents with four reviewed for maintaining activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide the necessary level of assistance for Resident (R)65 during mealtime to maintain his abilities. This deficient practice placed R65 at risk for impaired nutrition and a decline in his ADL. Findings Included: - The Medical Diagnosis section within R65's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), cerebral infarction (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), history of falling, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness). R65's admission Minimum Data Set (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 - R46's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic pain, and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R46 required extensive assistance from one staff member for activities of daily living (ADLs). The MDS documented R46 required supervision for bathing during the observation period. The Quarterly MDS dated 12/08/23 documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R46 required partial/moderate assistance with bathing during the observation period. R46's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/21/23 documented R46 had generalized weakness and required assistance with ADLs. R46's Care Plan dated 09/14/23 documented that staff would provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 67 residents. The sample included 17 with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)60's low air-loss mattress pump was set up to his appropriate weight requirements and failed to provide wound care per R60's ordered treatment. The facility additionally failed to assess R8's pressure wounds upon admission. This deficient practice placed R60 and R8 at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and osteomyelitis (local or generalized infection of the bone and bone marrow). A review…

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 67 residents. The sample included 17 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to assess ongoing patterns of incontinence to establish bowel and bladder patterns in order to identify measures to maintain or improve Resident (R)53's incontinence. This deficient practice placed R53 at risk for complications related to incontinence. Findings included: - The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of vitamin B insufficiency, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), muscle weakness, and abnormalities of gait and mobility. A review of R53's Quarterly Minimum Data Set (MDS) completed 10/10/23 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated he required supervision or touch…

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 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to complete weekly weight monitoring as ordered by the physician for Resident (R)60 and failed to weigh R13 weekly upon admission per acceptable standards of practice. This deficient practice placed both residents at risk for complications related to weight loss. Findings Included: - The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and osteomyelitis (local or generalized infection of the bone and bone marrow). A review of R60's admission Minimum Data Set (MDS) completed on 12/08/23 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS indicated he was dependent on staff assistance for bed mobility, bathing, toileting, and transfers. The MDS noted he…

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 67 residents. The sample included 17 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to maintain and store Resident (R)42's continuous positive airway pressure device (CPAP - ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) equipment in a sanitary manner. This deficient practice placed R42 at risk for complications related to respiratory infections. Findings Included: - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), major depressive disorder (major mood disorder), morbid obesity (severely overweight), sleep apnea (a disorder of sleep characterized by periods without respirations), and coronary atherosclerosis (mineral build-up on the walls of the heart's blood vessels). R42's Quarterly Minimum Data Set (MDS) completed 12/14/23 noted a Brief Interview for Mental Status (BIMS)…

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 67 residents. The sample included 17 residents with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 55's access site for signs of infection, and bleeding, and failed to obtain communication from the dialysis center and assess post-dialysis. These deficient practices placed R55 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R55's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 67 residents. The sample included 17 residents with five sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of blood pressure and pulse monitoring for Resident (R)32 before administration of Cozaar (an antihypertensive medication used to treat high blood pressure and heart failure) as ordered by the physician. The facility failed to ensure the CP identified and reported R28's blood pressure and pulse lacked monitoring as the physician ordered. The CP did not identify and report R55 was on an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality) medication which lacked an appropriate indication for use or the required physician documentation. This deficient practice placed R32, R28, and R55 at risk for unnecessary medications and possible adverse side effects. Findings included: - The electronic…

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 67 residents. The sample included 17 residents with five sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 32's physician-ordered blood pressure and pulse were monitored prior to the administration of Cozaar (an antihypertensive medication used to treat high blood pressure and heart failure). The facility failed to ensure R28's blood pressure and pulse were monitored as the physician ordered. This deficient practice placed R32 and R28 at risk for unnecessary medications and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R32 documented diagnosis of hypertension (elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) for R32 dated 11/24/23 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R32 was independent to supervision for functional abilities. R32…

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 67 residents. The sample included 17 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R)55, who had a diagnosis of Alzheimer's and dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R55's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia, Alzheimer's, and anxiety (mental or emotional reaction characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 67 residents. The sample included 17 residents with five reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to prevent a significant medication error when Resident (R) 24 received twice the physician-ordered dose of Eliquis (medication used to thin the blood) from 11/30/23 to 01/02/24. The deficient practice placed R24 at risk for adverse effects including bleeding related to the medication error. Findings Included: - R24's Electronic Medical Record (EMR) documented diagnosis of occlusion and stenosis of the left carotid artery (narrowing, constriction, or blockage of either of the two main arteries that supply blood to the head), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), generalized muscle weakness and cognitive communication deficit. The admission Minimum Data Set (MDS) dated 11/16/23 documented a Brief Interview for Mental Status…

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 53 residents. Based on observation, record review, and interview, the facility failed to ensure that resident's rights and dignity were respected by staff when Resident (R)6 was not offered to eat in the dining room at meals, and staff failed to provide drinks and meals to all residents at the table when meals were served to R17, R205, and five unidentified resident at the table; staff placed clothing protectors on residents from behind without asking the resident if they wanted one; and staff failed to provide privacy while providing cares for R21, which left these residents at risk for decreased self-esteem and decreased self-worth. Findings included: - On 04/04/22 at 09:37 AM R6 stated that she had to eat her meals in her room and not been offered the option to eat in the dining room. On 04/05 at 08:09 AM R17 sat in Broda chair (a wheelchair that provides assistance with tilt-in-space positioning and chair functionality to people who sit all day) at a table in the commons area when he reached for an unidentified residents drink on the table…

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 at census of 53 residents. The sample included 16 residents with 16 residents was reviewed for comprehensive care planning. Based on observation, record review, and interview, the facility failed to implement comprehensive care plans for Residents (R)30, R44, R49, R13, and R205. This deficient practice placed the residents at risk for not receiving proper cares/assistance in a timely manner. -The electronic medical record (EMR) indicated the following diagnosis for R30: muscle weakness, major depressive disorder (major mood disorder). hypertensive heart disease (chronic high blood pressure), insomnia (difficulty falling asleep), traumatic brain injury (TBI), constipation, and abnormalities of gait and coordination. A review of R30's admission Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of seven indicating intact cognition. The MDS revealed she was occasionally incontinent of bowel and bladder with no toileting program A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 53 residents. The sample included 16 residents with 11 reviewed for bathing. Based on observations, record reviews, and interviews, the facility failed to provide consistent bathing per the residents' preferences and bathing schedules for Residents (R) 30, R44, R49, R225, R6, R17, R27, R39 and R45. This deficient practice placed the residents at risk for poor hygiene and impaired psychosocial well-being. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R30: muscle weakness, major depressive disorder (major mood disorder). hypertensive heart disease (chronic high blood pressure), insomnia (difficulty falling asleep), traumatic brain injury (TBI), constipation, and abnormalities of gait and coordination. A review of R30's admission Minimum Data Set (MDS) completed 02/17/22 indicated a Brief Interview for Mental Status (BIMS) score of seven indicating intact cognition. The MDS reported that supervision and touch assistance were…

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 53 residents and three medication carts. Based on observation, record review, and interview, the facility failed to properly date five individual insulin (a hormone which regulates blood sugar) pens in one of the three medication carts. This deficient practice left the residents being administered these insulins at risk for adverse consequences or less effective medication treatment. Findings included: - On [DATE] at 07:50 AM, the nurse's medication cart on the south 100 hall contained the following insulin pens: one Novolin N flex pen (an intermediate-acting insulin that starts to work within two to four hours, and keeps working for 12 to 18 hours) that was opened and not dated ; one Lantus pen (a long-acting insulin) that was opened and not dated; one Novolog aspart insulin pen (a short-acting insulin that lasted four to six hours) that was opened and not dated; and Basaglar Kwik Pen (a long-acting insulin) that was opened and not dated; and one Levemir (a long-acting…

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 53 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to maintain a sanitary and clean wound field when providing wound care for R3, failed to ensure that facility staff properly dated, stored and cleaned supplemental oxygen (O2) equipment for resident (R)6, R23, and R49, failed to ensure that facility staff did proper hand hygiene while passing meal trays to residents, failed to ensure that facility staff properly transported clean laundry to residents, and failed to ensure that staff sanitized/cleaned a mechanical lift (a machine that assists in the transfer of a resident) after use. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - On 04/06/22 at 10:50 AM, Licensed Nurse (LN) H and Consultant HH entered R3's room to perform wound assessment and wound care. LN H closed the door and blinds, raised the bed, then performed hand hygiene and donned (put on) gloves. Consultant HH performed hand hygiene 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 identified at census of 53 residents. The sample included 16 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that resident (R)13's call light was within reach and able to call for assistance with personal cares. This deficient practice left R13 vulnerable for not receiving proper cares/assistance in a timely manner. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. The admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R13…

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 53. The sample included 16 residents. Based on interview and record review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) for Individuals with Mental disorders and Individuals with Intellectual Disability was completed for Resident (R) 42. This placed the resident at risk for decreased or inadequate care and services related to his mental health diagnoses and intellectual disabilities. Findings include: - R42's Electronic Medical Record (EMR) recorded diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), obsessive-compulsive disorder (OCD - anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational,…

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 53 residents. The sample included 16 residents; three residents reviewed for activities. Based on observations, record reviews, and interviews, the facility failed to consistently provide activities for Resident (R) 205, R6, and R17. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence. Findings included: - R205 admitted to facility on 01/07/22. The Diagnoses tab of R205's Electronic Medical Record (EMR) documented diagnoses of anoxic brain injury (condition caused by a complete lack of oxygen to the brain), need for assistance with personal care, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and history of falling. The admission Minimum Data Set (MDS) dated 01/14/22, documented a Brief Interview for Mental Status (BIMS) was not completed due to R205 rarely/never understood. R205 required extensive physical assistance with two staff for bed…

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

The facility identified a census of 53 residents. The sample included 16 residents; three residents sampled for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) review. Based on observations, record reviews, and interviews, the facility failed to ensure prevention of cross-contamination during wound care for Resident (R) 3 and failed to ensure heel protectors were worn at all times as ordered for R21 who had a history of heel wounds. This deficient practice had the risk for prolonged wound healing, development or worsening of wounds, and unwarranted physical complications for R3 and R21. Findings included: - The Diagnoses tab of R3's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer of sacral (large triangular bone between the two hip bones) region stage three (wound that extends into the subcutaneous [beneath the skin] tissue layer) and need for assistance with personal care. The admission Minimum Data Set (MDS) dated 10/01/21…

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 53. The sample included 16 residents with two residents reviewed for elopement. Based on observation, interviews, and record review, the facility failed to ensure a safe environment for Resident (R)42, when R42 eloped (when a cognitively impaired resident leaves the facility without staff knowledge or supervision) from the facility. This placed R42 at risk for injuries from accidents or hazards. The facility further failed to implement care planned interventions aimed to protect R225 and R205 from injuries related to falls and failed to thoroughly investigate and determine the root cause of falls for R205. This placed the residents at increased risk for injury related to falls. Findings included: - R42's Electronic Medical Record (EMR) recorded diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures),…

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 53 residents. The sample included 16 residents with three reviewed for catheter and incontinence care. Based on observations, record reviews, and interviews, the facility failed to provide consistent incontinence care for Resident's (R) 30 and R44, and catheter care for R225. This deficient practice placed the resident at risk for infections and impaired psychosocial well-being. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R30: muscle weakness, major depressive disorder (major mood disorder). hypertensive heart disease (chronic high blood pressure), insomnia (difficulty falling asleep), traumatic brain injury (TBI), constipation, and abnormalities of gait and coordination. A review of R30's admission Minimum Data Set (MDS) completed 02/17/22 indicated a Brief Interview for Mental Status (BIMS) score of seven indicating intact cognition. The MDS revealed she was occasionally incontinent of bowel and bladder with no toileting program. A review of R30's Activities of Daily Living (ADL's) Care Area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 53 residents. The sample included 16 residents, with three residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to provide necessary respiratory care and services for Resident (R) 6, R23, and R49 when the facility failed to date and store oxygen tubing (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) for R6, and failed to clean, date and store the equipment in accordance with professional standards of practice for R23 and R49. These deficient practice placed the resident's at risk for respiratory infection and/or illness. Findings included: - R6's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of chronic respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide and the lungs are unable to carry the blood to the organs), chronic obstructive pulmonary disease (COPD-…

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 53 residents. The sample included 16 residents with one resident reviewed for behavioral health. Based on record review, and interviews, the facility failed to provide an environment that promoted Resident (R)42's emotional and psychosocial well-being when the facility failed to develop and implement person-centered plan of care to support R42's behavioral health needs. The facility failed to identify and implement individualized interventions specific to R42's mental health diagnoses and his behaviors and failed to identify triggers or stressors which contributed to behavioral manifestations. The facility further failed to evaluate the care and services for effectiveness related to R42's behaviors. This deficient practice placed R42 at risk for impaired psychosocial wellbeing and inadequate behavioral health care. Findings included: - R42's Electronic Medical Record (EMR) recorded diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality,…

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 53 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to provide the needed dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 13, which placed her at risk for increased behaviors, confusion. decline in ability to maintain the highest practicable mental and psychosocial well-being. This deficient practice placed her at risk of increased confusion, isolation, and lack of appropriate activities and interaction. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbances and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) left lower limb. 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 identified a census of 53 residents. The sample included 16 residents; six sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of behavior monitoring for R39, R13, and R27 who received psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications including antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), medications; and the lack of an indication for administration for Lasix (diuretic- medication to promote the formation and excretion of urine) for R13. This deficient practice had the risk for unnecessary medication use and physical complications for all residents affected. Findings included: - R39 admitted to facility on 03/02/22. The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of bipolar (major mental illness that caused people 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 identified a census of 53 residents. The sample included 16 residents; six sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to provide consistent bowel monitoring and failed to obtain an order to administer an as needed (PRN) laxative (medication used to loosen stool or stimulate a bowel movement) for Resident (R) 45; failed to ensure carvedilol (antihypertensive- medication used to treat hypertension [high blood pressure]) was not given outside ordered parameters for R205; failed to ensure an indication for administration for Lasix (diuretic- medication to promote the formation and excretion of urine) was documented for R13. This deficient practice had the risk for unnecessary medication use and physical complications. Findings included: - The Diagnoses tab of R45's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder) and psychotic disorder (any major mental disorder characterized…

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 53 residents. The sample included 16 residents; six sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure an as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had a 14-day stop date or a documented rationale for extended duration for R39 and facility failed to provide behavior monitoring for R39, R13, and R27 who received psychotropic medications, including antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications. This deficient practice had the risk for unnecessary medication use and physical complications for all residents affected. Findings included: - R39 admitted to facility on 03/02/22. The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods)…

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.