Pioneer Ridge Retirement Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 50. Findings included:- R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypotension (low blood pressure) 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 admission Minimum Data Set (MDS) dated 11/17/25 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R50's Falls Care Area Assessment (CAA) dated 11/25/25 documented she triggered for falls related to impaired balance and history of falls. R50's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 62 residents. The sample included 17 residents with five reviewed for care plan. Based on observation, record review, and interviews, the facility failed to implement a comprehensive care plan for Resident (R) 54 related to his activities of daily living (ADL).Findings Included: - R54's Electronic Medical Records (EMR) noted diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion).R54's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 62 residents. The sample included 17 residents with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 38 and R27's care plans to reflate changes in their care.Findings Included: - R38's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), limited mobility, muscle weakness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R38's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted she could independently complete bathing, dressing, bed mobility, and transfers. The MDS noted she was at risk for developing pressure ulcers but had no current injuries. The MDS noted she had pressure-reducing devices in place for her bed and wheelchair. R38's…

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

The facility identified a census of 62 residents. The sample included 17 residents, with one reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure the physician order was followed for a daily weight for R45 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). Findings included:- R45's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypotension (low blood pressure), CHF, and atrial fibrillation (rapid, irregular heartbeat). The admission Minimum Data Set (MDS) dated 11/10/25 documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated intact moderately impaired cognition. The MDS documented R45 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. R45's Dehydration Care Area Assessment (CAA) dated 11/16/25 documented he had triggered for dehydration related to constipation. The nursing staff would monitor for signs or symptoms 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 62 residents. The sample included 17 residents, with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 2, and further failed to ensure R2's Low air loss (LAL) mattress (medical device that uses continuous airflow through small holes in the surface to reduce moisture, keep skin cool and dry, and redistribute pressure to prevent and treat pressure ulcers) was set at the proper weight. Findings Included:- R2's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), senile degeneration of brain (a progress degeneration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 62 residents. The sample included 17 residents, four residents were sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 2's fall interventions as directed by her care plan.Findings included:- R2's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), senile degeneration of brain (a progress degeneration of the brain with age) and dementia (a progressive mental disorder characterized by failing memory and confusion).The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R2 was dependent on the staff for bathing and toileting. The MDS documented R2 had falls since admission or reentry or the prior assessment. The MDS documented R2 had…

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

The facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for respiratory care. Based on interviews, observation, and record review, the facility failed to ensure there was physician indication for oxygen administration for Resident (R) 27. Findings included:- R27's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated 10/09/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented that R27 had received respiratory treatment during the observation period. R27's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 04/29/25 documented R27 required staff assistance with his functional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for dialysis (a procedure where impurities or wastes are removed from the blood), and end-stage renal disease (ESRD- a terminal disease of the kidneys). Based on observation, record review, and interviews, the facility failed to provide standards of care related to Resident (R) 7's dialysis.Findings included:- R7's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid) and end stage renal disease (the final stage of chronic kidney disease, where the kidneys have permanently stopped working and can no longer function at a level needed to sustain life).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R7 was impaired on one side of his body. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 62 residents. The sample included 17 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 3 and R1. Findings included:- R3's Electronic Medical Records (EMR) noted diagnoses of heart failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), overactive bladder, and morbid obesity (severely overweight). R3's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. The MDS noted she could independently complete bathing, transfers, showering, dressing, personal hygiene, toileting, and footwear. The MDS noted she reported she had little interest in doing things and had feelings of hopelessness.…

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 three residents. Based on observations, record review, and interviews, the facility failed to report an allegation of abuse between staff and Resident (R) 1 to the State Agency (SA) as required. This deficient practice placed R1 at risk for unidentified and ongoing abuse.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of pain, insomnia (inability to sleep), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS) dated 02/20/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.The Quarterly MDS dated 05/15/25, documented R1 had a BIMS score of 15, which indicated intact cognition.The Functional Abilities Care Area Assessment (CAA) dated 02/25/25, documented R1 had intact cognition and was able to let staff know his needs and wants.R1's Care Plan dated 07/25/25, documented staff provided R1 with medications and other measures 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 61 residents. The sample included nine, with one reviewed for competent staffing. Based on interviews and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to identify the available epinephrine (medication used to alleviate symptoms of severe allergic reactions) during Resident (R) 1's anaphylaxis episode. This deficient practice placed R1 and all residents with allergies at risk for impaired quality of care. Findings included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), blindness of right eye, acute kidney failure, and fracture (broken bone) of the right femur (thigh bone). R1's EMR indicated he was admitted on [DATE] for therapy services related to his recent right femur fracture. R1's EMR…

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 - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), 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) affecting the dominate right side. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R29 was independent with transfers, changes in position, and ambulation was not tested. The MDS documented R29 had no falls during the observation period. The Quarterly MDS dated 08/08/24 documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R29 was independent with transfers, changes in position, and ambulation. The MDS documented R29 had no falls during the observation period. R29's Falls 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.

The facility identified a census of 45 residents. The sample included 13 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 32, R10, R46, and R34. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R32's clinical record revealed the PCV13 was administered on 11/09/23. R32's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R10's clinical record revealed the PCV13 was administered on 10/24/19. R10's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R46's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of any historical administration. 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 45 residents. The sample included 13 residents. One resident was sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)45 had a call light within her reach. This deficient practice left R45 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings included: - R45's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of 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), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting left dominant side, dysphagia (swallowing difficulty), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin),…

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 45 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notice for a facility-initiated transfer as soon as practicable for Resident (R) 31. This deficient practice placed R31 at risk of uninformed choices and miscommunication regarding care needs. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, overweight, neoplasm (tumor) of right breast, and back pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R31 needed substantial to maximum assistance with transfers. R31's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on observations, record review, and interview the facility failed to provide a bed hold notice with the required information to Resident (R) 31 and/or their legal representative when R31 transferred to the hospital. This deficient practice placed R31 at risk for impaired ability to return to the facility or her same room. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, overweight, neoplasm (tumor) of right breast, and back pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R31 needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with three residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 45's offloading boots were applied to her heels to prevent pressure ulcers. The facility also failed to ensure that R29's pressure-relieving cushion was in his wheelchair. This placed R45 and R29 at increased risk for worsening pressure ulcers and the development of new pressure ulcers. Findings Included: - R45's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of aphasia (a condition with disordered or absent language function) following cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow 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 45 residents. The sample included 13 residents with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 45's palm splint was applied. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R45's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of 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), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting left dominant side, dysphagia (swallowing difficulty), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is…

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 45 residents. The sample included 13 residents with one resident observed for bowel and bladder. Based on observation, record reviews, and interviews the facility failed to assess, identify, and implement interventions related to Resident(R)31's incontinence. This deficient practice placed R31 at risk of impaired dignity and increased risk for urinary tract infections (UTI). Finding included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, overweight, neoplasm (tumor) of right breast, and back pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R31 needed substantial to maximum assistance with toileting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident(R) 21's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This placed R21 at an increased risk for respiratory infection and complications. Findings included: - R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), thrombocytopenia (abnormally low number of platelets, the parts of the blood that help blood to clot,…

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 45 residents. The sample included 13 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Residents (R)12 and R46 had a documented safety assessment for the use of side rails that addressed entrapment, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) noted diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), aphasia (difficulty speaking), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). R12's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 13 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to notify Resident (R)21's physician according to the physician-ordered parameters for blood glucose monitoring. This deficient practice placed R21 at risk for delayed treatment of hyperglycemia (greater than the normal amount of glucose in the blood) and unnecessary medication complications. Findings included: - R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), thrombocytopenia (abnormally low number of platelets, the parts of the blood that help blood to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 45 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)34 and R32 had a stop date for as-needed (PRN) lorazepam (anxiety medication). This placed the residents at risk for adverse effects from psychotropic (alters mood or thoughts) medication. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following 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) of the left non-dominant side, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, attention deficit disorder, hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder…

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 45 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure that physician-ordered laboratory test results for Resident (R) 31 were included in R31's clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, overweight, neoplasm (tumor) of right breast, and back pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R31 needed substantial to maximum assistance with toileting hygiene. The MDS documented that R31 did not have a trial 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 identified a census of 45 residents. The sample included 13 residents with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)45. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R45's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of 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), hemiparesis/hemiplegia (weakness and paralysis…

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 45 residents. The facility identified five residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP and personal protective equipment (PPE) for Resident (R) 7 and R32. The facility additionally failed to store respiratory equipment in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 10/14/24 at 07:05 AM a walkthrough of the facility was completed with the following observations noted: An inspection of R7's room revealed no EBP indicator signage or personal protective equipment in or around her room related to her wounds. An inspection of R32's room revealed no EBP indicator signage or personal protective equipment in or around her room related to…

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

The facility identified a census of 51. The sample included 13 residents. Based on interviews and record review, the facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life. Findings included: - A review of the facility's activity calendars for April, May, June, and July 2023 indicated church services on Sundays and Always Available Items marked for Saturdays. The calendars noted no other activities on the weekends. The activity calendar for April, May, and June 2023 revealed no activities scheduled on any Sunday except afternoon church services. In a confidential interview with the resident council on 07/18/2023, several residents reported that though there were weekday activities, the facility did not provide any structured activities on most Saturdays and Sundays. The council reported they had church on Sundays, but the rest of the day had no scheduled activities. On 07/19/2023 at 01:20pm Activities Staff Z reported the facility provided…

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 51 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food borne illnesses and food safety concerns. Findings included: - On 07/17/23 at 07:40 AM an observation in the kitchen's dry food storage room revealed one opened bag of marshmallows. The bag was open to air and undated. On 07/17/23 at 07:42 AM an observation in the kitchen's dry food storage room revealed one opened bag of elbow macaroni. The bag was undated. On 07/17/23 at 07:43 AM an observation in the kitchen's dry food storage room revealed one opened package of spaghetti noodles. The package was undated. On 07/17/23 at 07:46 AM an observation in the kitchen's dry food storage room revealed one plastic storage container of rice. The container was not labeled and lacked a date. On 07/17/23 at 07:48 AM an observation in the main kitchen area revealed a plastic storage…

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 51 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene, medical equipment storage/cleaning, and catheter care. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 07/17/23 the facility reported no residents were on transmission-based precautions. On 07/17/23 at 0709 AM an inspection of the Blue Hall revealed an oxygen tank (cylindrical tank used to provide supplemental oxygen), tubing, and nasal cannula (tubing that delivers oxygen directly through both nostrils of the nose) stored on the back of a wheelchair outside Resident (R)45's room. The nasal cannula and tubing hung down the back of the wheelchair and rested against the back of wheelchairs seat. No storage bag or protective barrier was present. The oxygen tank's gauge meter was in the red (empty). The tubing was not dated and labeled. On 07/17/23 at 07:11AM an inspection of the Blue Hall transfer…

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 51. The sample included 13 residents with two reviewed for dignity. Based on interviews and record review, the facility failed to provide dignified care for Residents (R)206 and R30. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R206's Electronic Medical Records (EMR) included diagnoses of spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), hemiplegia (left sided paralysis of one side of the body), hemiparesis (left sided muscular weakness of one half of the body), major depressive disorder (major mood disorder), insomnia (difficulty sleeping), and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). R206 admitted to the facility on [DATE] for respite care. R206 had not had a Minimum Data…

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 51 residents. The sample included 13 residents with three residents reviewed for beneficiary notices review. Based on observation, record review, and interviews, the facility failed to provide Resident (R)6 with an Notice of Medicare Non-coverage (NOMNC CMS-form 10123) and Advanced Beneficiary Notice (ABN CMS-10055) with Medicare-Part A days remaining. This deficient practice placed R6 at risk for delayed care and missed services. Findings Included: - A review of R6 EMR revealed an Medicare End of Stay Minimum Data Set (MDS) completed on 04/14/23 noting she was being discharge for Medicare part A services but expected to remain in the facility. A review of R6's EMR indicated her last covered day for Medicare part A services was 04/15/23. On 07/19/23 R6's Beneficiary Notification Review was completed. The review indicated the facility-initiated her discharge from therapy services but R6 was not provided an ABN or NOMNC form. A review of the Centers for Medicare and Medicaid Services (CMS) requirements indicated the facility was required to issue…

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 51 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for Resident (R) 9 for special treatment and programs when the MDS documented she received dialysis (a process of removing excess water, solutions, and toxins from the blood) during the look back period. This deficient practice placed R9 at risk for inappropriate care planning and care needs. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), unspecified psychosis (any major mental disorder characterized by a gross impairment in reality testing), and major depressive disorder (major mood disorder). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 51 residents. The sample included 13 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 42's comprehensive care plan to include administration of oxygen. This deficient practice placed R42 at risk for the potential alteration of continuous care among nursing home staff, that could result in adverse consequences related to respiratory distress and adverse side effects. Findings included: - R42's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), sleep apnea (disorder of sleep characterized by periods without respirations), and major depressive disorder (major mood disorder). 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 that R42…

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 51 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to ensure that physician ordered daily weights were obtained and monitored for Resident (R) 45 who had congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R45 at risk for unwanted weight/fluid gain and possible complications. Findings included: - The electronic medical record (EMR) for R45 documented diagnoses of CHF, chronic kidney disease (condition characterized by a gradual loss of kidney function over time), biventricular heart failure (a condition of both left and right-sided heart of the resulting in shortness of breath and a build-up of fluid), and diabetes mellitus (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] documented R45 had a Brief Interview for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure care planned fall interventions were followed for Resident (R) 1 after a fall on 06/25/23. This deficient practice placed R1 at risk for additional falls and possible injury. Findings included: - The electronic medical record (EMR) for R1 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), peripheral vascular disease (PVD- abnormal condition affecting the blood vessels), osteoarthritis (chronic arthritis without inflammation), and constipation (difficulty passing stools). The Annual Minimum Data Set (MDS) dated [DATE] for R1 documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. R1 required extensive assist of one staff for activities of daily living (ADLs). R1's balance was not steady and was only able to stabilize with staff…

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

The facility identified a census of 51 residents. The sample included 13 with two reviewed for nutrition. Based on observation, interviews, and record review, the facility failed to provide consist weekly weight monitoring as identified on Resident (R)14's nutritional care plan. This deficient practice placed R14 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Finding included: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of protein-calorie malnutrition, legal blindness, dementia (progressive mental disorder characterized by failing memory, confusion), and spondylosis (age-related condition where the joints and cartilage lined discs of the neck are affected). R14's Annual Minimum Data Set (MDS) completed 06/08/2023 noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to severe cognitive impairment. The MDS indicated she required extensive assistance from two staff for transfers, bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 51 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician was notified when antihypertensive medication (class of medication used to treat hypertension (high blood pressure) was not administered for Resident (R) 39 and blood sugars were outside of parameters for R7. This deficient practice placed these residents at risk for unnecessary medication use and possible unwarranted side effects. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (major mood disorder), and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual 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 The facility identified a census of 51 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 9 did not receive antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) for an extended duration when staff failed to change a scheduled dose in response to a physician ordered gradual dose reduction (GDR) and failed to ensure the as needed (PRN) antipsychotic medication did not extend for a duration longer than 14 days without physician visit and rationale. The facility further failed to ensure an appropriate indication, or the required physician documentation, for continued use for R36's Seroquel (antipsychotic medication). This deficient practice placed R9 and R36 at risk for unnecessary psychotropic (alters mood or thought) medications and adverse side effects. Findings included: - R9's Electronic Medical Record (EMR) from the…

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