Medicalodges Leavenworth

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident(R) 27'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 and nasal cannula was stored in a sanitary manner. This placed R27 at an increased risk for respiratory infection and complications. Findings included: - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of pressure-induced deep tissue damage of left heel, reduced mobility, need for assistance with personal cares, muscle weakness, obesity, osteomyelitis (local or generalized infection of the bone and bone marrow), hypertension (HTN-elevated blood pressure), sleep apnea (a disorder of sleep characterized by periods without respirations), and ), depression (a mood disorder that causes a persistent…

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 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the medication regimen review (MRR) was addressed by the physician for Resident (R) 3 and R26. The facility also failed to ensure the Consultant Pharmacist (CP) identified and recommended a gradual dose reduction (GDR) for R3's psychotropic (alters mood or thought) medications. The facility further failed to ensure the CP identified and reported irregularities for R9's non-Center for Medicaid and Medicare (CMS) approved indication for an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and lack of physician documentation for ongoing use without a gradual dose reduction (GDR)attempted. These deficient practices placed the residents at risk for unnecessary medication use, side effects, and physical complications. Findings…

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 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9 had a Center for Medicare and Medicaid Services (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) or the required physician documentation. The facility further failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale for R9 and R3. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration regarding Resident (R) 8's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided to these residents by hospice. This deficient practice created a risk of missed opportunities for services and delayed physical, mental, and psychosocial needs for R8. Findings included: - R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and altered mental status. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The sample included three residents reviewed for abuse and/or neglect. Based on record review, and interview the facility failed report an allegation of abuse to the State Agency (SA) for Resident (R)1 within the required timeframe. This placed R1 at risk for ongoing abuse and/or neglect. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of senile degeneration of brain, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and insomnia (inability to sleep). The Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility on [DATE]. Review of the Assessments tab recorded a Clinical Health Review completed on 08/22/23 which documented no skin concerns or discoloration. Review of the Tasks: Monitory Skin Observation completed 08/22/23 through 08/27/23 documented no red areas, discolorations or skin concerns. The admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The sample included three residents reviewed for abuse and/or neglect. Based on record review, and interview the facility failed to investigate bruising of unknown origin for Resident (R)1. This placed R1 at risk for unidentified and ongoing abuse and/or neglect. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of senile degeneration of brain, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and insomnia (inability to sleep). The Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility on [DATE]. Review of the Assessments tab recorded a Clinical Health Review completed on 08/22/23 which documented no skin concerns or discoloration. Review of the Tasks: Monitory Skin Observation completed 08/22/23 through 08/27/23 documented no red areas, discolorations or skin concerns. The admission Progress Note dated 08/22/23…

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 31 residents. The sample included four residents. Based on record review, interviews, and observations, the facility failed to ensure that Licensed Nurse (LN) staff followed standards of practice regarding reconciliation of controlled narcotic substances when staff signed the narcotic control log verifying removal and destruction of fentanyl (controlled pain medication with high likelihood for abuse) patches without actually visualizing or verifying and another occasion when staff wasted a fentanyl patch with no witness. This deficient practice placed the four residents identified by the facility as using fentanyl patches at risk for unnecessary side effects related to fentanyl and risk of diversion/misappropriation of fentanyl patches. Findings included: - Review of the R1's fentanyl Narcotics Count Sheet documented on 08/12/23 at 07:00 AM Licensed Nurse (LN) H wasted a fentanyl patch with no witness signature verifying the waste and destruction of the patch. On 08/12/23 at 08:00 AM R1 had a fentanyl patch applied to his right should and LN J…

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 31 residents. The sample included four residents reviewed for fentanyl (controlled narcotic medication with high risk for abuse) patch use. Based on interview, record review, and observation, the facility failed to ensure Licensed Nurse (LN) staff possessed the skills necessary to provide competent nursing services for Resident (R)1 when staff placed a new fentanyl patch without ensuring removal of the previous patch. This deficient practice placed the resident at risk for incompetent nursing care, and unnecessary side effects related to fentanyl. Findings included: - R1's Electronic Medical Record (EMR) documented under the Diagnoses tab the following diagnoses: Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), chronic pain syndrome, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and spinal stenosis…

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 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to ensure the privacy of protected health information (PHI) for 39 residents. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Findings Included: - On 04/04/23 at 07:10AM an initial walk-through of the facility revealed a treatment cart with three used COVID-19 (highly contagious, potentially life-threatening respiratory virus) test swabs on top of the cart in the main entry area next to the dining hall. A resident census was left unsecured and in full view on top of the treatment cart which revealed the COVID-19 status of all 39 residents in the facility. On 04/10/23 at 07:00AM a treatment cart was placed at the entrance of the facility which contained a list on top of the cart residents awaiting COVID-19 results, unattended and in full view. On 04/10/23 at 12:03PM Licensed Nurse (LN) G stated all PHI related to the resident's care should not be left out for others to view. She stated…

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

The facility identified a census of 39 residents. Based on observation, record review and interview, the facility failed to ensure that there was a registered nurse (RN) on staff for at least eight consecutive hours, seven days a week. This deficiency had the potential for poor quality of care and negative outcomes for the residents. Findings included: - Review of the facility daily staffing sheets and actual working schedule from 10/01/21 to 04/06/23 revealed the facility did not provide proof of having eight consecutive hours of RN coverage on 48 days during that period. The facility failed to provide proof of RN coverage on the following dates from 11/21/21 to 12/31/21 (11/21/21, 11/25/21, 12/18/21). The facility failed to provide proof of RN coverage on the following dates from 01/01/22 to 03/30/22 (01/08/22, 01//09/22, 01/29/22, 02/05/22, 02/06/22, 02/12/22, 02/13/22, 02/26/21, 02/26/22, 02/27/22, 03/13/22, and 03/27/22). The facility failed to provide proof of RN coverage on the following dates from 04/01/22 to 06/30/22 (04/02/22, 04/24/22, 04/30/22, 05/01/22, 05/07/22,…

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 39. The sample included 13 residents with five residents positive for COVID-19 (highly contagious, potentially life-threatening respiratory virus). Based on observations, record review, and interviews, the facility failed to ensure COVID-19 test swabs were stored properly during and after use, failed to prevent cross-contamination during wound care for R25, and failed to ensure soiled isolation personal protective equipment (PPE- equipment used to protect the wearer from hazardous contaminates and substances) was stored in a way to prevent exposure to other residents and staff. This deficient practice had the risk to spread illness to all residents. Findings included: - On 04/04/23 at 07:10AM an initial walk-through of the facility revealed a treatment cart with three used COVID-19 test swabs on top of the cart in the main entry area next to the dining hall. A resident census was left unsecured and in full view on top of the treatment cart which revealed the COVID-19 status of all 39 residents in the facility. On 04/04/23 at 11:11 AM, R140'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 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends. This deficient practice placed 39 residents at risk for decreased psychosocial wellbeing. Findings Included: - A review of the facility's Activity Calendar for January, February, and March of 2023 indicated the weekends followed the same three activities of Free Time, Resident Ran Bingo, and Easy Listening Music. The schedule indicated activities available in T.V. room. On 04/05/23 at 03:33PM, Resident Council members reported the facility did not provide weekend activities. The council reported Resident (R)8 often held a bingo game on weekends, but rarely other interactive events would be available. The council reported that activities such as Free Time, Music, and Chit Chat consisted of residents were taken to an area to sit around without engagement or socialization. On 04/10/23 at 11:15AM Activities Coordinator (AC) X stated that he provided activities to the residents…

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 39 residents. The sample included 13 residents with four residents reviewed for accidents. Based on observation, record review and interview the facility failed to secure hazardous materials out of reach of the residents. The facility additionally failed to protect Resident (R)190 from accessing hazardous materials and medical waste. The facility failed to ensure R4's was left at a safe height to prevent fall related injuries. These deficient practices placed the residents at risk for preventable injuries and accidents. Findings Included: - On 04/04/23 at 07:05AM an initial walk-through of the facility revealed five residents on isolation (R5, R6, R12, R33, and R36). The isolation boxes contain germicidal bleach wipes left unsecured on top of the boxes. The wipes contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. An inspection of the unlocked Weight Room revealed an overfilled Sharps (bin to place used needles 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 39. The sample included 13 residents with one resident sampled for resident rights/dignity. Based on observation, record review, and interview, the facility failed to ensure that resident rights and dignity were respected by staff when Resident (R) 140 was not provided privacy while he received cares. This deficient practice placed R140 at risk for decreased self-esteem and decreased self-worth. Findings included: - On 04/04/23 at 07:10AM an initial walk-through of the facility revealed staff assisted R140 with dressing by Certified Nursing Aide (CNA) O. R140 sat on his bed with his pants around his thighs and his groin area exposed. The door was open and there was no privacy curtain in place to protect R140's privacy. On 04/10/23 at 11:37 AM CNA M stated any time that care was provided to a resident, privacy should be provided. CNA M said the resident's door should be closed, or the curtain pulled to protect privacy during cares. On 04/10/23 at 11:58 AM Licensed Nurse (LN) G stated a resident's door should be shut or the curtain pulled over 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 39 residents. The sample included 13 residents with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)16's call light was within reach and failed to provide R190 wheelchair foot pedals during transport. This deficient practice placed both residents at risk for preventable accidents and injuries. Findings Included: - The electronic medical record (EMR) for R16 documented diagnoses of major depressive disorder (major mood disorder), cognitive communication deficit, unsteadiness of feet, abnormalities of gait and mobility, and a history of falls. R16's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she required extensive assistance from two staff for bed mobility, transfers, dressing, personal hygiene, and bathing. The MDS indicated she…

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 39 residents with 13 residents included in the sample. The facility identified three residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue the CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 which contained the required information for Resident (R) 240. This failure placed the resident at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R240's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 11/11/22 and ended on 12/08/22. R240 was discharged home from the facility. The facility failed to provide evidence that the NOMNC was given to R240. On 04/06/23 at approximately 09:00 AM, Administrative Nurse D and Administrative Staff A stated that the facility did not have a NOMNC for R240. She further stated that it had been completed; however, they did not…

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 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to maintain a safe, homelike environment related for Resident (R) 8. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected resident. Findings Included: - On 04/04/23 at 10:11AM R8 reported that the floorboard on her wall was damaged, and she had requested to have it replaced multiple times. She stated that part of the floor paneling was falling off the wall. She stated that the facility told her, we'll replace it when you move out. She stated it has been damaged for months, but no one has fixed it. She also stated an outlet cover had been left off her wall. An inspection of the wall verified the entire right side of her back wall had paneling pulled outward. A large fixture hole was four feet above her bed from an outlet with no cover. A review of the facility's Maintenance logs revealed no work orders placed for the damages. A review of the facility'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 39 residents. The sample included 13 residents with three residents reviewed for hospitalization. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)24 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R24. Findings included: - R24 was hospitalized on [DATE], 05/10/22, 06/02/22, 07/21/22, 09/18/22, 01/24/23, 03/24/23, and 04/05/23. R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute kidney failure (damaged kidneys and unable to filter blood the way they should), cognitive communication deficit, and diabetes mellitus (when the body cannot use…

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 39 residents. The sample included 13 residents with one sampled resident reviewed for baseline care plan. Based on observation, record review and interview, the facility failed to ensure Resident (R)140's care plan addressed a care area for oxygen (O2) therapy/use. This deficient practice placed R140 at risk for unmet care needs and increased respiratory complications and a decline in his well-being. Findings included: -The electronic medical record for R140 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), acute respiratory failure with hypoxia (when the lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning), cardiac arrhythmia (an irregular heartbeat), and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial pain). The admission Minimum Data Set (MDS) for R140 had not been completed yet as R140 was admitted…

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 39 residents. The sample included 13 residents with one sampled resident reviewed for intravenous (IV) antibiotic (a medication used to treat infections) use. Based on observation, record review and interview, the facility failed to ensure staff initiated a care plan area for Resident (R) 36 to direct staff on the care for his IV antibiotic care/use. This deficient practice placed R36 at risk of unmet care needs, increased infection, and adverse side effects related to IV fluid and medication administration. Findings included: - The electronic medical record (EMR) for R36 documented diagnosis of methicillin-resistant staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics), and sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock). The admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents. The sample included 13 residents with one resident reviewed for hospice and end of life. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 24's care plan with direction or care for dialysis (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). This deficient practice placed R24 at risk of delayed services or adverse risk of complication related to dialysis. Findings included: - R24 was hospitalized on [DATE]. R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute kidney failure (damaged kidneys and unable to filter blood the way they should), cognitive communication deficit, and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief…

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 39 residents. The sample included 13 residents and three closed records reviewed with one for hospitalization. Based on record review, and interviews, the facility failed to document a recapitulation and discharge summary of the facility stay upon discharge from the facility for Resident (R) 39. This deficient practice placed R39 at risk for an interruption in the continuity of care. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), muscle weakness, and kidney failure (damaged kidneys and unable to filter blood the way they should). The Entry tracking Minimum Data Set (MDS) dated [DATE]. The Discharge Assessment dated 01/11/23. R39's Baseline Care Plan dated 04/05/23 documented R39 was working with therapy to build his strength and mobility to return to the community. The Care Plan documented R39's family was supportive. The Care Plan documented the facility would assist R39 with…

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

The facility identified a census of 39 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to follow physician ordered daily weights for Resident (R) 15 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R15 at risk for excess fluid accumulation and physical complications. Findings Included: - R15's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), heart failure, mild cognitive impairment, history of COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death), psychotic 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 39 residents. The sample included 13 residents with one resident reviewed for pressure injuries. Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 25, who was on antibiotic (medication used to treat bacterial infections) for a wound infection. This deficient practice placed R25 at risk of wound worsening and complications related to infections. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, carpal tunnel syndrome (a group of problems that includes numbness, tingling, weakness, or pain in the wrist or hand), and cognitive communication deficit. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented that R25 was dependent on assistance of two staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4 and R25 received treatment and services to prevent an avoidable reduction in range of motion (ROM) and/or mobility for their multiple contractures (abnormal permanent fixation of a joint). This deficient practice left R4 and R25 at risk for further decline and decreased ROM or mobility. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of contractures of muscles, multiple sites, contracture of elbow, muscle weakness, and dependence on wheelchair. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented that R4 was dependent on assistance of two staff for activities of daily living (ADLs). The MDS documented no falls for R4 during the look back period.…

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 39 residents. The sample included 13 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to provide services to improve/maintain Resident (R)9's bladder incontinence. This deficient practice placed the resident at risk for complications related to incontinence. Findings Included: - The electronic medical record (EMR) for R9 documented diagnoses of major depressive disorder (major mood disorder), history of urinary tract infections (UTI), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and dementia (progressive mental disorder characterized by failing memory, confusion). R9's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to her severe cognitive impairment. The MDS indicated she required…

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 39 residents. The sample included 13 residents with one sampled resident reviewed for intravenous (IV) medications. Based on observation, record review and interview, the facility failed to ensure Resident (R) 36 received care and services for the provision of parenteral fluids (administration occurring elsewhere in the body than the mouth) consistent with professional standards of practice. The facility failed to ensure R36 had a physician's order for the normal saline (NS-saline water solution) flush to be administered via IV before and after administration of IV medications. This deficient practice placed R36 at risk of infection, and adverse side effects related to IV fluid and medication administration. Findings included: - The electronic medical record (EMR) for R36 documented diagnosis of methicillin-resistant staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics), and sepsis (a systemic reaction that develops when the chemicals in the immune…

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 39 residents. The sample included 13 residents with two sampled residents reviewed for respiratory care. Based on observation, record review and interview, the facility failed to ensure Resident (R)140 had a physician's order for oxygen (O2) therapy/use. The facility further failed to ensure R140's O2 tubing/nasal cannula (NC- a hollow tube used to supply supplemental O2). This deficient practice placed R140 at risk for increased respiratory complications and infection and a decline in his well-being. Findings included: -The electronic medical record for R140 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), acute respiratory failure with hypoxia (when the lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning), cardiac arrhythmia (an irregular heartbeat), and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial…

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 39 residents. The sample included 13 residents with one resident reviewed for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 24's central venous catheter (central line- a catheter placed in a large vein) for signs of infection, bleeding, and proper dressing in place. This deficient practice placed R24 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R24 was hospitalized on [DATE]. R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute kidney failure (damaged kidneys and unable to filter blood the way they should), cognitive communication deficit, and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents. The sample included 13 residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide dementia care and services for Resident (R)190. This deficient practice placed R190 residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing. Findings Included: - The electronic medical record (EMR) for R190 documented diagnoses of dementia, major depressive disorder (major mood disorder), macular degeneration (progressive deterioration of the retina), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and history of falling. R190's EMR indicated he admitted to the facility on [DATE]. A review of R190's Care Plan created 03/27/23 indicated he required assistance from one staff for ambulating,…

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 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to ensure the Consulting Pharmacist (CP) identified and reported Resident (R)15's insulin (hormone which regulates blood sugar) medication given outside the physician ordered parameters. This deficient practice placed R15 at risk for unnecessary medication and side effects. Findings included: - R15's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), heart failure, mild cognitive impairment, history of COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms 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 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to follow the medical provider's parameters related to Resident (R)15's insulin (hormone which regulates blood sugar) medication. This deficient practice placed R15 at risk for unnecessary medication and side effects. Findings Inlcuded: - R15's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), heart failure, mild cognitive impairment, history of COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death), psychotic disorder (psychosis - any…

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 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to provide an acceptable indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use for use for R15's Seroquel (antipsychotic - class of medications used to treat psychological and emotional conditions medication). This deficient practice placed R15 at risk for unnecessary medications and side effects. Findings included: - R15 Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), heart…

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 39 residents. The sample included 13 residents with one sampled resident reviewed for hospice services. Based on observation, record review and interview, the facility failed to ensure Resident (R)140 had a hospice plan of care in place and available for facility staff direction on hospice provided care. This deficient practice placed R140 at risk for unmet hospice care/services and a decline in his well-being. Findings included: -The electronic medical record for R140 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), acute respiratory failure with hypoxia (when the lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning), cardiac arrhythmia (an irregular heartbeat), and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial pain). The admission Minimum Data Set (MDS) for R140 had not been completed yet as R140 was…

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

The facility identified a census of 39 residents. The sample included 13 residents with five residents reviewed for influenza (a contagious respiratory illness that infect the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interview the facility failed to ensure Resident (R)10, R15, and R16, who consented to receive the pneumococcal vaccine, were administered the vaccination. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease. Findings included: - Review of R10's Immunization tab in the EMR and a copy of R10's Vaccine Consent Form revised 05/2021 to receive the pneumococcal vaccine dated 11/28/21 per verbal consent from R10's responsible party. R10 did not receive the pneumococcal vaccine. Review of R15's Immunization tab in the EMR and a copy of R15's Vaccine Consent Form revised 05/2021 to receive the pneumococcal vaccine dated…

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

The facility had a census of 41 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. Finds included: - On 07/19/21 at 01:18 PM, Administrative Nurse D revealed that she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Furthermore, she revealed the facility lacked a certified Infection Preventionist. The facility's Infection Preventionist policy, dated 11/01/19, documented the facility will ensure the Infection Preventionist works at least part-time at the facility, is adequately qualified, and meets eligibility requirements by completing specialized training in infection prevention and control through accredited continuing education. The facility failed to ensure the person designated as the Infection Preventionist completed the required certification, placing the residents 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 41 residents. The sample included 16 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified irregularities (target behaviors being monitored) for four residents of five sampled for medication review: resident (R)16, R20, R32, and R34. Findings included: - The electronic medical record (EMR) for R16 documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), aphasia (a condition with disordered or absent language function), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS) dated [DATE] for R16 documented a Brief Interview for Mental Status (BIMS) score of five which indicated a severe cognitive impairment. He required supervision to 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 identified a census of 41 residents. The sample included 16 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified irregularities (target behaviors being monitored) for four residents of five sampled for medication review: resident (R)16, R20, R32, and R34. Findings included: - The electronic medical record (EMR) for R16 documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), aphasia (a condition with disordered or absent language function), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS) dated [DATE] for R16 documented a Brief Interview for Mental Status (BIMS) score of five which indicated a severe cognitive impairment. He required supervision to 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.

The facility identified a census of 41 residents. 30 medication administrations were observed for three residents. Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than five percent (%), with 12 errors affecting Resident (R) 1, making the medication error rate 40%. Findings included: - R1's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and history of pneumonia (inflammation of the lungs). Review of R1's physician orders revealed R1 lacked an order which allowed the medications to be crushed and mixed for administration. On 09/16/21 at 09:10 AM Administrative Nurse E crushed and mixed 12 medications, then added 60 cubic centimeters (cc's) of water for R1, to be administered through his percutaneous endoscope gastrostomy (PEG-tube- a tube inserted through the wall of the abdomen…

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 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to record the medication room refrigerator in one of two medication rooms. Findings included: - On 09/13/21 at 07:45 AM during initial tour of the facility with Administrative Nurse D, the medication room near the nurses' station by entry door lacked recorded refrigerator temperatures for medication refrigerator for September 1 through September 13, 2021. On 09/13/21 at 07:45 AM Administrative Nurse D verified nursing staff should check the temperature daily and record the thermometer reading on the refrigerator check sheet. Upon request the facility failed to provide a medication storage policy. The facility failed to document medication room refrigerator temperature for September 1 through September 13, 2021, placing the residents at risk of receiving ineffective medication.

The facility identified a census of 41 residents. The facility had one main kitchen. Based of observation and interview, the facility failed to store food (opened food items that were not labeled or dated), and utilize proper personal hygiene practices (e.g., proper hand washing and the appropriate use of gloves), to prevent contamination of food. Findings included: - Observation during the initial tour of the main kitchen on 09/13/21 at 7:27 AM revealed in the main freezer there was an open bag of frozen broccoli florets that did not have an open date on it and was not in a sealed bag. The refrigerator had a plastic bag that had cooked bacon slices in it. The bag was not dated or labeled. There was a bag of lunchmeat dated 8/7 that was not labeled with the contents. The dry storage area had an opened bag of pancake mix, and opened bags of white and chocolate cake mix that had not been re-bagged and labeled with the contents. During observation on 09/14/21 at 10:22 AM of Dietary Staff CC getting ready to prepare the puree foods for two residents, it was noted that she did not wash…

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 41 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure a staff member correctly used hand hygiene and infection control standards when passing ice to the resident rooms. Findings included: - On 09/15/21 at 10:30 AM observation revealed Certified Nurse Aid (CNA) N with insulated cooler on a cart, CNA N not wearing gloves retrieved a drinking cup from room [ROOM NUMBER], opened the lip, scooped ice, and poured it into the cup. The scoop touched the inside rim of the cup with the scoop. The cup was held over the container of ice with lid open. He then placed the lid and straw back on the cup and delivered back to the room. CNA N then entered room [ROOM NUMBER], brought the cup from the room, held it above the open lid of the cooler, scooped ice into the cup, placed the lid and straw on it and returned it to the room. CNA N did not wash hands or use alcohol-based foam or gel between rooms. On 09/15/21 at 10:30 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.

The facility had a census of 41 residents. The sample included 16 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide five of five residents (R), R1, R11, R19, R25 and R32, with the current Center for Disease Control and Prevention (CDC) pneumococcal, influenza, and coronavirus immunizations. Findings included: - R1's record review documented the resident received the influenza immunization outside the facility. The record lacked documentation of where and when R1 received the immunization. The record also lacked documentation of the pneumococcal status and second coronavirus immunization. R11's record lacked documentation of the influenza immunization status. R19's record lacked documentation of the influenza and pneumococcal immunization status. R25's record lacked documentation of the pneumococcal immunization status. R32's record review lacked documentation of pneumococcal immunization status. On 09/16/21 at 12:12 PM Administrative Nurse D verified the resident's records lacked documentation of immunization status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 16 residents, of which two dependent residents were reviewed for bathing. Based on observation, record review, and interviews the facility failed to provide consistent bathing for Resident(R) 25 and R34, who were dependent on staff for bathing. This placed R25 and R34 at increased risk for poor hygiene and decreased psychosocial wellbeing. Findings included: -R25's Physician Order Sheet (POS), dated 8/2/21, documented diagnoses of cerebral infarction (CVA- 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), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had severe cognitive impairment, was totally dependent on one staff for bathing, always incontinent of urine…

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 41 residents. The sample included 16 residents, with three residents reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed ensure Prafo (pressure reducing ankle foot orthotic) boots were placed on Resident (R) 1's bilateral lower extremities to prevent pressure ulcers. This placed R1 at increased risk for pressure ulcer development. Findings included: - R1's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and history of pneumonia (inflammation of the lungs). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief…

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 41 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to maintain activities of daily living (ADL) to prevent decline for Resident (R) 24 when they failed to restorative nurse care. This placed R24 at risk for a decline in range of motion (ROM) and decreased functional ability. Findings included: - R24's Physician Order Sheet (POS), dated 09/09/21, documented diagnoses of hypertension (elevated blood pressure), metatarsalgia ( a condition in which the ball of the foot becomes painful and inflamed), atypical atrial flutter (a condition in which the heart's upper chambers beat too quickly), unspecified fracture of upper end of right humerus (the bone of the upper arm that connects the shoulder to the elbow), and muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, required extensive assistance of one to two staff for activities of daily living (ADLs), was not…

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 census was 41. The sample included 16 residents with five residents reviewed for accidents. Based on observation, interview, and record review the facility failed to provide protective oversight and supervision for one of two sampled residents for accidents and/or hazards. Resident (R)6 admitted to the facility for skilled services on 01/25/21 after sustaining injuries in a motor vehicle accident (MVA). The facility failed to have a system in place to evaluate, assess, and identify a plan of care to ensure R6 was safe to leave the facility on multiple occasions and failed to ensure he was safe to operate a motor vehicle. R6 experienced multiple hypoglycemic (low blood sugar levels) episodes during this time and received physical therapy (PT), occupational therapy (OT) and speech therapy (ST) services for cognitive impairment, lack of coordination, and need for assistance with personal care. The facility failed to properly document when R6 left and returned to the facility. This deficient practice placed R6…

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 41 residents. The sample included 16 residents, which three residents reviewed for catheter care. Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for a resident with an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag) when the facility failed to provide catheter care for Resident (R) 20, which placed R20 at risk for catheter related complications. Findings included: - R20's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), methicillin resistant staphylococcus aureus infection (MRSA-a type of bacteria resistant to many antibiotics), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 16 residents and one resident (R) reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients though a tube). Based on observation, record review, and interviews, the facility failed to ensure R1's head of bed (HOB) remained at 45 degrees to prevent the increased risk of complications of aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). Findings included: - R1's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and history of pneumonia (inflammation of the lungs). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 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 41 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed ensure Resident (R) 94 was free from medication errors when he did not receive his physician ordered enoxaparin (anticoagulant- class of medications used to prevent the formation of blood clots). This deficient practice placed R94 at risk for increased complications and symptoms related to his development of possible blood clots post-surgery. Findings included: - R94 's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of right femoral (thigh bone) fracture (broken bone), hypertension (elevated blood pressure), and old myocardial infraction (history of a heart attack). The Medicare Five Day Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R94 required extensive assistance of two staff members for activities of daily living…

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.