The Healthcare Resort Of Kansas City

Based on observation, record review, and interview, the facility failed to keep the facility free from pests and maintain an effective pest control program when ants were seen in the east dining room. Findings included:- On 05/12/26 at 09:47 AM, an observation noted ants crawling across the table in the east dining room. On 05/12/26 at 09:47 AM, Dietary Staff BB stated she had reported to maintenance that there had been ants noted on the table in the east dining room. On 05/13/26 at 09:15 AM, Administrative Staff C stated pest control came to the facility monthly and as needed when pests were noted in between the visits. Administrative Staff C stated an order was put in the TELS (a building management platform designed for senior living with integrated asset management, life safety, and maintenance solutions). On 05/13/26 at 01:30 PM, Maintenance U stated that he had been notified by a resident in the dining room and by staff of the ants yesterday. Maintenance U stated pest control came to the facility monthly and as needed. The pest control was called and would be coming tomorrow…

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 Based on observation, record review, and interview, the facility failed to ensure Resident (R)6 and R43's call light was within his reach to enable him to call for staff assistance. Findings included:- R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).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.

Based on interviews, observation, and record review, the facility failed to ensure a discharge summary was completed and a recapitulation of Resident (R) 83's stay at the facility. The facility also failed to notify the state ombudsman of his discharge from the facility. Findings included:- R83's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic pain and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing).R83's EMR revealed a Nursing Note: dated 04/10/26 at 03:06 PM, that documented R83 was to be discharged home with his medications and all his personal belongings. Discharge instructions were reviewed with R83 and voiced no concerns.The Facility provided the Ombudsman notification for the past three months. Review of the items provided by the facility revealed the facility had sent copies of the bed-hold and hospital transfers to the state ombudsman's office.On 05/13/26 at 09:25 AM, Administrative Staff C stated she was unable 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 Based on observation, record review, and interview, the facility failed to implement and activities program to support Resident (R)6's social needs with involvement in both individual and group activities in order to support his highest psychosocial wellbeing when staff failed to offer and provide one on one activity or diversions from his red bag of activities in his room. Findings included:- R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness,…

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.

Based on observations, record review, and interviews, the facility failed to provide adequate care and services to promote the healing of 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) for Resident (R) 4, and R43 when staff failed to provide their heel boots. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pressure ulcer and Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) to right and left…

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 Based on observation, record review, and interviews, the facility failed to provide care and services to prevent further decline in range of motion when staff failed to place Resident (R)6's hand splint on his left hand for contracture (abnormal permanent fixation of a joint or muscle) prevention. Findings Included:- R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness, and Parkinson's disease (a slowly progressive neurologic 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 Based on interviews, observation, and record review the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the cognitively impaired, independently mobile residents. The facility additionally failed to ensure fall interventions were in place for Resident (R) 53 and R16, which placed the residents at risk for preventable accidents and injuries. Findings included:- On 05/12/26 at 08:01 AM, during the initial walkthrough of the facility, an unsecured oxygen storage room revealed on the west hallway. The room contained 34 pressurized supplemental oxygen cylinder tanks stored in floor racks. The room had a key lock on the entry door.On 05/12/26 at 08;17 AM, an oxygen cylinder sat in the corner directly on the floor of R77's room. The oxygen cylinder cart was in R77's room. The oxygen cylinder was not placed in a cart. 1. R53's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of repeated falls, disorientation, 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.

Based on interviews, observation, and record review the facility failed to ensure Resident (R)43 received treatment and services for enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) to prevent complications or adverse consequences when staff did not position R43 to prevent potential aspiration. Findings included:- R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of aphasia (condition with disordered or absent language function), gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).The admission Minimum Data Set (MDS) dated 01/27/26 documented severely impaired cognition. The MDS documented R43 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) on the upper and lower…

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.

Based on observation, record review, and interviews, the facility failed to provide services consistent with the standards of care related to the care of Resident (R) 4's peripherally inserted central line (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to follow the physicians order for the in-facility removal of the PICC line when the intravenous antibiotic was finished for three days, failed to document the full removal of the line including the tip and failed to adequately monitor the site for complications after removal. Findings included: - R4's EMR from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused 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 Based on observation, record review, and interviews, the facility failed to provide adequate respiratory care and services for Resident(R) 77's. bilevel positive airway pressure (BiPAP- a noninvasive ventilator that helps breathing), and her nasal cannula, when staff failed to ensure the equipment was stored in a sanitary manner when not in use. Findings included:- R77's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure (the lungs cannot adequately supply oxygen to the blood (hypoxemia) or remove carbon dioxide, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), sleep apnea (a disorder of sleep characterized by periods without respirations), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and pneumonia (an infection in the lungs).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview 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 Based on observation, record review, and interviews, the facility failed to provide effective pain management, including ongoing assessment and monitoring for effectiveness of pain relief, for Resident (R)16, who had pain. Findings Included:- R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), contracture (abnormal permanent fixation of a joint or muscle) of muscle, muscle weakness, and lupus (an autoimmune disease that damages the immune system damage organs and tissue throughout the body.The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R16 received pain medication and received as needed (PRN) medications or was offered and declined during the observation period. The Psychotropic Drug Use Care Area assessment dated [DATE] documented R16 was prescribed an antidepressant (a class of medications used to treat mood…

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.

Based on interviews, observation, and record review, the facility failed to provide dementia (a progressive mental disorder characterized by failing memory, and confusion) related care and services for Resident (R) 10 to promote his highest practicable level of well-being when staff failed to provide diversions and one to one attention per his plan of care. Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure).The admission Minimum Data Set (MDS) dated 02/16/26 documented a Brief Interview of Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R10 was dependent on staff assistance for mobility. R10's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/19/26, documented 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.

Based on observation, record review, and interview, the facility failed to store medication and biologicals adequately when staff failed to lock and secure an unattended medication cart. Findings included:- On 05/13/26 at 08:15 AM, the medication aide cart on the northeast hall was left unlocked and unattended when Certified Medication Aide (CMA) R stepped away from his cart to go into a resident's room.On 05/13/26 at 02:07 PM, the medication cart for the northeast hall was left unlocked. The cart was CMA R's, who was cleaning up the medication cart for the southeast hall. Administrative Nurse E walked up to the cart and locked the cart.On 05/13/26 at 08:17 AM, CMA R stated he only stepped away from his cart briefly, but he should have locked it when he stepped away from it.On 05/13/26 at 08:18 AM, Licensed Nurse (LN) H stated the medication cart should be locked anytime you walk away from the cart or when not being used.On 05/13/26 at 02:07 PM, Administrative Nurse E stated that the medication carts should always be locked when staff walk away from the cart. Administrative Nurse E…

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.

Based on record reviews and interviews, the facility failed to offer and administer or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) and influenza (highly contagious viral infection) vaccination for Resident (R)3. Findings included: - Review of R3's clinical record revealed refusals for PCV20 and influenza vaccines. R3's clinical record lacked documentation the PCV20, and influenza was offered or declined, and lacked documentation of a historical administration or a physician documented contraindication.05/13/26 at 08:40 AM, Administrative Nurse C stated she was unable to find R3's declination.On 05/14/26 at 02:51 PM, Administrative Nurse D stated the nurse that was admitting the resident was responsible to ensure the resident or family signed a consent or declination for immunizations. She stated the facility had changes in the administration, and the infection preventionist should be the one following up on any consent or declination of immunizations.The facility did not provide an immunization policy…

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 66 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 07/10/24 at 10:40 AM a review of the training for agency Certified Nurses Aid (CNA) P, CNA Q, and CNA LL revealed the following: CNA P's facility-provided credentialling file lacked evidence training was completed for communication training. CNA Q's facility-provided credentialling file lacked evidence training was completed for communication training. CNA LL's facility-provided credentialling file lacked evidence training was completed for communication training. On 07/10/24 at 10:45 AM Administrative Staff A stated during orientation with the agency employees, staff go over the curriculum with agency staff which included timekeeping and meal breaks, the smoking policy, cell phone and social media, the dress code, dietary services, fall prevention, infection control, abuse, customer…

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 66 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required resident's rights training. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 07/10/24 at 10:40 AM a review of the training for agency Certified Nurses Aid (CNA) P, CNA Q, and CNA LL revealed the following: CNA P's facility-provided credentialling file lacked evidence training was completed for resident's rights training. CNA Q's facility-provided credentialling file lacked evidence training was completed for resident's rights training. CNA LL's facility-provided credentialling file lacked evidence training was completed for resident's rights training. On 07/10/24 at 10:45 AM Administrative Staff A stated during orientation with the agency employees, staff go over the curriculum with agency staff which included timekeeping and meal breaks, the smoking policy, cell phone and social media, the dress code, dietary services, fall prevention, infection control,…

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 66 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required dementia training for nurse aides. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 07/10/24 at 10:40 AM a review of the training for agency Certified Nurses Aid (CNA) P, CNA Q, and CNA LL revealed the following: CNA P's facility-provided credentialling file lacked evidence the required in-service training was completed for nurse aides. CNA Q's facility-provided credentialling file lacked evidence the required in-service training was completed for nurse aides. CNA LL's facility-provided credentialling file lacked evidence the required in-service training was completed for nurse aides. On 07/10/24 at 10:45 AM Administrative Staff A stated during orientation with the agency employees, staff go over the curriculum with agency staff which included timekeeping and meal breaks, the smoking policy, cell phone and social media, the dress code, dietary services, fall…

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

The facility had a census of 66 residents. The sample included 19 residents with five reviewed for accidents. Based on observation, record review and interview the facility failed to ensure a safe environment free from potential hazards out of reach of the five cognitively impaired, independently mobile residents. The facility additionally failed to follow the fall prevention interventions care planned for Residents (R)29 and R58. The facility additionally failed to ensure R6's room was free from physical hazards. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings Included: -On 07/08/24 at 07:09 AM an inspection of the main lobby's kitchenette next to the receptionist revealed an accessible kitchenette entrance with a cleaning chemical bottle and Microkill wipes. All the cleaning products identified contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. A pressurized carbon dioxide (CO2 - pressurized gas) sat unsecured in a cabinet under the sink. On 07/08/24 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 reported a census of 66 residents. The facility identified one medication room and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure its medication and treatment carts. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included- - On 07/08/24 at 07:06 AM an inspection of the East Hall nursing station revealed an unlocked skin treatment cart. The cart contained assorted medicated lotions with the avoid ingestion and contact poison control warnings. At 07:20 AM an inspection of the [NAME] Hall station revealed an unsecured medication cart. The cart contained R39's Cefdinir (medication used to treat bacterial infections) and Junuvia (medication used to lower blood glucose) pill packs left unsecured on top of the cart. The medication cart was not secured. The cart stored stock medication and prescription medications for residents in the [NAME] Hall. At 07:25 AM Licensed Nurse (LN) J verified the unsecured medications and medication carts. He stated the…

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

The facility identified a census of 66 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, medication administration, and disposal of personal protective equipment (PPE). These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 07/08/24 at 07:21 AM soiled towels were placed on the ground for a large leak in front of the drink station of the [NAME] Hall kitchenette. On 07/08/24 at 08:01 AM a soiled glove and broken facemask were left on top of the EBP cart outside of R48's room. On 07/09/24 at 07:25 AM a pile of bed linen was on the floor of R39's floor. On 07/09/24 at 07:28 AM, soiled damp towels and clothing were placed on the floor of R6's room next to the bathroom. On 07/09/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)39 foot pedals for her wheelchair. This deficient practice left R39 vulnerable to possible injury due to unmet care needs. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dysarthria (weak speech), pacemaker( and artificial device to stimulate the heart muscle), transient ischemic attack (a temporary blockage of blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), difficulty in walking, cerebral infarction (stroke - the 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) affect right dominant side, depression (a mood…

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 66 residents. The sample included 19 residents with two residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure that residents were free from resident-to-resident abuse when Resident (R) 31 threw hot coffee on R40. This placed R40 and other residents on the west hall at risk of possible harm and or injury and impaired quality of life. Findings included: - The electronic medical record (EMR) for R31 documented diagnoses of hemiplegia and hemiparesis (muscular weakness and paralysis of one side of the body), diabetes mellitus (DM- -when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN- elevated blood pressure), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS) dated 10/07/23 for R31 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 had impairment to one…

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 66 residents. The sample included 19 residents with two residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure a resident-to-resident altercation was fully investigated and interventions implemented to prevent further abuse after R31 threw hot coffee on R40. This placed the residents on the west hall at risk of possible harm and or injury and impaired quality of life. Findings included: - The electronic medical record (EMR) for R31 documented diagnoses of hemiplegia and hemiparesis (muscular weakness and paralysis of one side of the body), diabetes mellitus (DM- -when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN- elevated blood pressure), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS) dated 10/07/23 for R31 documented a Brief Interview for Mental Status (BIMS) score of 15 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 66 residents. The sample included 19 residents. Based on observation, record review and interview the facility failed to ensure staff obtained physician-ordered labs for Resident (R) 45 and the facility failed to notify the physician of the delay in R45's labs being obtained. This placed R45 at risk of delayed care and related complications. Findings included: - The electronic medical record (EMR) for R45 documented diagnoses of hypertension (HTN- elevated blood pressure), urinary tract infection (UTI-an infection in any part of the urinary system), and compression fracture (occurs when one or more bones in the spine weaken and crumple) of the lumbar vertebra. R45's admission Minimum Data Set (MDS) dated 06/12/24 documented that R45 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R45 required partial/moderate assistance from staff for functional abilities. R45 was dependent on staff for toileting and bathing. R45 was frequently incontinent of the bladder and occasionally incontinent of bowel. R45 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66 residents. The sample included 19 residents with two residents reviewed for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 39's leg/ankle brace was applied to her right leg when she was out of bed to prevent her contractures (abnormal permanent fixation of a joint or muscle) from worsening. This deficient practice left R39 at risk for further decline and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). or mobility. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dysarthria (weak speech), pacemaker( and artificial device to stimulate the heart muscle), transient ischemic attack (a temporary blockage of blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hemiparesis/hemiplegia (weakness…

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 66 residents. The sample included 19 residents with two residents observed for bowel and bladder. Based on observation, record reviews, and interviews the facility failed to ensure the standard of care was provided for Resident (R)39, who had a history of urinary tract infection (UTI-an infection in any part of the urinary system). This deficient practice placed R39 at risk of complications and further UTIs. Finding included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dysarthria (weak speech), pacemaker( and artificial device to stimulate the heart muscle), transient ischemic attack (a temporary blockage of blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), difficulty in walking, cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen…

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 66 residents. The sample included 19 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 consistently communicate Resident (R) 6's medical condition prior to and post-hemodialysis. This deficient practice placed R6 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypotension (low blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys) with dialysis (procedure where impurities or wastes were removed from the blood), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, 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.

The facility reported a census of 66 residents. The sample included 19 with one reviewed for behavioral health services. Based on record review, observations, and interviews, the facility failed to adequately meet Resident (R)46's behavioral health needs related to utilizing non-pharmacological care approaches resulting in repeated behavioral episodes. This deficient practice placed R46 at risk for continued behavioral episodes and unmet care needs. Findings Included: - The Medical Diagnosis section within R46's Electronic Medical Records (EMR) included diagnoses of metabolic encephalopathy (brain disorder resulting in confusion, agitation, and thought dysfunction), cognitive-communication disorder, unsteadiness on her feet, muscle weakness, insomnia (difficulty sleeping), and a need for assistance with personal cares. R46's admission Minimum Data Set (MDS) completed 05/09/24 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she exhibited verbal and physically aggressive behaviors one to three days of the…

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

The facility identified a census of 66 residents. The sample included 19 with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to identify a pattern of dementia-related behaviors for Resident (R)29 and implement meaningful interventions to promote quality of life. This deficient practice placed R29 at risk for preventable injuries and the inability to maintain her highest practicable level of functioning. Findings Included: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of dementia, cognitive communication deficit, insomnia (difficulty sleeping), and dysphagia (difficulty swallowing). R29's Significant Change Minimum Data Set (MDS) completed 04/25/24 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated no behaviors. The MDS indicated she required substantial to maximal assistance with bed mobility, bathing, dressing, toileting, and…

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

The facility identified a census of 66 residents. The sample included 19 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure staff followed physician-ordered parameters for Resident (R) 41 's antihypertensive (class of medication used to treat high blood pressure) medication monitoring. This placed the resident at risk of unnecessary medication administration and possible adverse side effects. Findings included: - R41's Electronic Medical Record (EMR) documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), myocardial infarction (heart attack), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). R41's Significant Change Minimum Data Set (MDS) dated 01/04/24 documented R41 had 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 had a census of 63 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to ensure a reconciliation of controlled medications at the end of daily work shifts. The facility further failed to ensure Resident (R)29's medications were available for administration as ordered by the physician. This placed residents at risk for misappropriation of medications by staff and ineffective medication regimen. Findings included: - On 10/26/22 at 08:50 AM, observation of the southwest-hall medication cart lacked evidence staff performed a reconciliation of controlled substances and signed the Controlled Medication Count Sheet at shift change 14 times from 10/01/22 to 10/26/22. On 10/26/22 at 09:12 AM, observation of the northwest-hall medication cart lacked evidence staff performed a reconciliation of controlled substances and signed the Controlled Medication Count Sheet at shift change 25 times from 10/01/22 to 10/26/22. On 10/26/22 at 08:50 AM,…

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 63 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to transport clean clothing in a sanitary manner and failed to adequately disinfect a glucometer (blood sugar reading machine). This placed the residents at risk for infectious disease processes. Findings included: - On [DATE] at 12:37 PM observation revealed Laundry Aide U delivered clean residents' personal clothes to hall 100 without a cover or barrier. Laundry Aide U stated she was not told the clean laundry should be covered. On [DATE] at 11:51 AM observation revealed Licensed Nurse (LN) H cleaned glucometer after use using disinfecting wipes. The container of wipes had an expiration date of 04/2021. LN H verified expiration date of 04/2021 and verified the wipes should not be used. On [DATE] at 12:39 PM Administrative Nurse D stated she thought she had removed all expired cleansing wipes. She further stated staff should utilize cleansing products which 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 had a census of 63 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify Resident (R)29's physician of medications not administered in a timely manner. This placed the resident at risk for physical decline. Findings included: - R29's Electronic Medical Record (EMR) documented R29 had diagnoses of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and pain (physical suffering or discomfort). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition and extensive assistance of one staff for transfers, dressing, and limited assistance of one staff for ambulation, toileting, and personal hygiene. The assessment further documented R29 received…

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 63 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for hypertension (high blood pressure) medication with signs and side effects of antihypertensive medications for one sampled resident, Resident (R) 29. This placed the resident at risk for physical decline and complications related to high blood pressure. Findings included: - The Electronic Medical Record (EMR) documented R29 had diagnoses of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and pain (physical suffering or discomfort). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition and extensive assistance of one staff for transfers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 63 residents. The sample included 19 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide scheduled bathing for one sampled resident, Resident (R) 16. This placed the resident at risk for skin problems and poor hygiene. Findings included: - R16's Physician's Order Sheet, dated 10/02/22, recorded diagnoses of end-stage renal disease (limited or no kidney function on a permanent basis that requires dialysis), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissue), cerebral vascular accident (interruption in the flow of blood to cells in the brain), hemiplegia (paralysis of one side of the body) diabetes mellitus (disease in which the body does not control the amount of glucose (a type of sugar) in the blood), and refractory depression (treatment resistant mood disorder that causes significant loss of interest in 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 had a census of 63 residents. The sampled included 19 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and failed to implement resident centered interventions for one sampled resident, Resident (R) 46. This placed the resident at risk for further falls and injury. Findings included: - R46's Electronic Medical Record (EMR) for R46 documented diagnoses of dementia with behavioral disorder (progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), diabetes mellitus type two (when the body cannot use glucose, not enough insulin made or the body cannot respond to insulin), and chronic kidney disease (when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R46 and severely impaired cognition and required extensive assistance of one…

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 63 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to accurately monitor the fluid intake for a 2000 milliliter (ml) per day fluid restriction for one sampled resident, Resident (R) 16. This placed the resident at risk for dehydration. Findings included: - R16's Physician's Order Sheet, dated 10/02/22, recorded diagnoses of end-stage renal disease (limited or no kidney function on a permanent basis that requires dialysis), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissue), cerebral vascular accident (interruption in the flow of blood to cells in the brain), hemiplegia (paralysis of one side of the body) diabetes mellitus (disease in which the body does not control the amount of glucose (a type of sugar) in the blood), and refractory depression (treatment resistant mood disorder that causes significant loss of interest in daily activities). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 63 residents. The sample included 19 residents with three reviewed for pain. Based on observation, record review, and interview, the facility failed to provide pain medication for one sampled resident, Resident (R) 172. This placed R172 at risk for further pain and discomfort. Findings included: - R172's Electronic Medical Record (EMR) documented R172 was admitted on [DATE] at 04:21 PM with diagnoses of closed fracture of the head of the right femur (broken bone), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), posttraumatic stress disorder (psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set, (MDS), dated [DATE], was in progress. The Pain Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 63 residents. The sample included 19 residents, with one reviewed for tube feeding. Based on observation, record review, and interview, the facility to ensure licensed nursing staff possessed the necessary knowledge and skills when staff administered Resident (R) 41's medication by mouth though the order read, and the licensed nurse was aware, the medications were ordered via percutaneous endoscopic gastrostomy (PEG) feeding tube (a feeding tube placed through the skin and stomach wall to allow nutrition, fluids and/or medication to be put directly into the stomach bypassing the mouth) by the physician. This deficient practice placed the resident at risk for aspiration. Findings included: - R41's Electronic Medical Record (EMR) documented R41 had diagnoses of dysphagia (swallowing difficulty), aphasia (condition with disordered or absent language function), hypertension (high blood pressure) and hemiplegia (paralysis of one side of the body). The Quarterly 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.

The facility had a census of 63 residents and five medication carts. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to label and store drugs and biologicals for two of five medication carts. This placed the affected residents at risk for ineffective medication regimens. Findings included: - On 10/26/22 at 08:15 AM, during initial tour of facility, observation revealed the Hall 100 nurse's medication cart had an insulin (medication used to regulate blood sugar) pen which lacked a date when opened for use for Resident (R) 20. Licensed Nurse (LN) H stated the insulin should have open date. On 10/26/22 at 01:23 PM observation reveal the Hall 100 medication cart was unlocked and unattended by staff. Observation further revealed cognitively impaired, independently mobile R8 in a wheelchair in the vicinity of the unlocked medication cart. Certified Medication Aide (CMA) R verified the medication cart was left unlocked. On 11/02/22 at 12:40 PM Administrative Nurse D verified insulin pens should be labeled with an opened date 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.