The Healthcare Resort Of Leawood - Iron Horse Hlth

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 64 residents. The sample included 16 residents, with five residents reviewed for 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 devices were in place for Resident (R) 12, who was at risk for the development of pressure ulcers. This deficient practice placed R12 at risk for complications related to skin breakdown.Findings included:- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of difficulty walking, dementia (a progressive mental disorder characterized by failing memory and confusion), lack of coordination, muscle weakness, and need for assistance with personal care.The admission Minimum Data Set (MDS) dated 04/22/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 64 residents. The sample included 15 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 3's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner. This placed R3 at an increased risk for respiratory infection and complications. Findings included:- R3's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), benign prostatic hyperplasia (urinary frequency, urgency, a weak or intermittent stream, needing to strain, a sense of incomplete emptying, and nocturia (frequent urination at night), acquired absence of right leg below the knee, acquired absence of left leg below the knee, peripheral vascular disease (a circulatory disorder where narrowed or blocked blood vessels reduce blood flow to the limbs, affection the arms, hands 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 64 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure physician-ordered laboratory test results for Resident (R) 42, R5, and R75 were included in the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.Findings included:- R5's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Overactive bladder, pain, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), cellulitis (a common bacterial infection of the skin and underlying tissues) of right lower limb, lack of coordination, communication deficit, need for assistance with personal car, closed fracture with routine healing, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness.The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 64 residents. The sample included 15 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) 13. This placed the resident at risk for inappropriate end-of-life care. Findings included:- R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), hypertension (high blood pressure), peripheral vascular disease (a circulatory disorder where narrowed or blocked blood vessels reduce blood flow to the limbs, often affection the…

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

The facility identified a census of 63 residents. The facility had one main kitchen and two kitchenette serving areas. Based on observation, record review and interview, the facility failed to ensure that dietary staff appropriately dated, labeled, and stored opened foods. This deficient practice had the potential for food borne illnesses for residents. Findings included: - On 11/13/23 at 07:37 AM during the initial tour of the facility's main kitchen observation revealed an opened box of cream of wheat in the dry storage area with a piece of plastic wrap over the top of the box; it was not in a sealed bag/container. There was a bag of spaghetti that was wrapped in plastic wrap that did not have a date on it. On 11/13/23 at 07:40 AM observation of the walk-in refrigerator revealed an open gallon plastic container of hard-boiled eggs. The lid was not closed to the container and there was no label that indicated the open date. There was an opened bag of diced potatoes that was not labeled and/or dated and was not stored in a sealed bag. There was an opened bag of pepperoni in a box…

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

The facility reported a census of 63. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life. Findings Included- - A review of the facility's Resident Council Minutes from 11/2022 through 11/2023 indicated the council had recurring concerns with staff not verifying meal tickets, offering choices, availability of snacks and fruits and vegetables, not taking orders before meal service, and posting the daily menus. Further recurring issues were call light response times. The Resident Council Minutes form instructed any old business that was unresolved be moved to new business. The 11/2022 Resident Council Minutes documented new business (concerns) that meal menus were not displayed, there were no snacks and fruit and/or vegetables were not always available. Further concerns included nursing staff were not asking the residents what they wanted or offering choices,…

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

The facility identified a census of 63 residents. The sample included 17 residents with two reviewed for grievances. Based on observation, record review, and interviews, the facility failed to adequately resolve Resident (R)26's grievances related to her ongoing dietary concerns. This deficient practice placed R26 at risk for decreased psychosocial wellbeing. Findings Included: - The Medical Diagnosis section within R26s Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R26's Quarterly Minimum Data Set (MDS) dated 08/22/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted she required set-up assistance from meals. The MDS noted no weight loss or swallowing disorders. R26's Nutritional Care Area Assessment (CAA)…

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

The facility had a census of 63 residents. The sample included 17 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure rooms containing hazardous materials out of reach of 17 cognitively impaired /independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings included: - On 11/13/23 at 07:08AM a walkthrough of the facility revealed two Spa rooms with doors propped open. Both rooms contained boxes of COVID-19 (highly contagious respiratory virus) testing kits in an unsecured closet. Both rooms had opened germicidal cylindrical containers of wipes stored on counter with the Keep out of reach from children warning. Certified Nurse's Aide (CNA) N secured the room. She reported the rooms should not be left open and unattended. On 11/16/23 at Licensed Nurse H stated cleaning solutions and hazardous chemicals should be locked in the cabinets when not in use or closely monitored. On 11/16/23 at 02:23PM…

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

The facility identified a census of 63 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care, disinfecting shared equipment, and storage of oxygen tubing when not in use. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - On 11/13/23 at 09:26 AM Resident (R) 18 sat in his wheelchair in his room with a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) on. In R18's bathroom, there was an oxygen concentrator (a device that provides supplemental oxygen) and the nasal cannula was lying on the floor. R18's continuous positive airway pressure (CPAP - a machine that used mild air pressure to keep breathing airways open while you sleep) mask was draped over the bedrail and not stored in a bag. Observation on 11/14/23 at 04:10 PM R15 laid on her bed. Her…

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

The facility identified a census of 63 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure that resident's rights and dignity were respected by staff when Resident (R) 16 and R1, both dependent residents, sat at the dining table as staff stood in between these residents to assist them with eating. This placed the residents at risk for decreased self-esteem and impaired dignity. Findings included: - On 11/13/23 at 12:48 PM R16 sat in his wheelchair at a dining room table and R1 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) on the other side of the same table. Certified Nurse Aide (CNA) O stood in between R16 and R1 while she assisted the two residents to eat. On 11/16/23 at 01:14 PM CNA N stated that staff should sit down beside a resident when assisting them to eat. CNA N stated staff should not ever stand to assist a resident to eat to respect their dignity. On 11/16/23 at 01:27 PM Licensed Nurse G stated staff should be seated next to a resident while assisting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 63 residents. The sample included 17 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Resident (R)26, R4, and R15. This deficient practice placed both residents at risk for infections, skin breakdown, and impaired dignity. Findings Included: - The Medical Diagnosis section within R26's Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord)., major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R26's Quarterly Minimum Data Set (MDS) dated 08/22/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she was dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 63 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to ensure the standard of care was provided during catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care and failed to prevent the catheter drainage bag from touching the floor for Resident (R)15 who had a history of frequent urinary tract infection (UTI-an infection in any part of the urinary system). This deficient practice placed R15 at risk of catheter related complications and further UTIs. Findings included: - R15's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and neuromuscular dysfunction of bladder (the muscles that control the flow 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 63 residents. The sample included 17 residents with five residents sampled for nutrition. Based on observations, record review, and interviews, the facility failed to ensure ordered dietary supplements, to promote increased calorie intake, were monitored for effectiveness and failed to ensure weekly weights were obtained as ordered for Resident (R) 59. This deficient practice placed R59 at risk for continued weight loss and possible malnutrition. Findings included: - R59's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) 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) affecting left side, generalized muscle weakness, other lack of coordination, and cognitive communication deficit (an impairment in organization, sequencing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 63 residents. The sample included 17 residents with five residents sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R) 18's pulse was not being monitored as physician ordered prior to administration of carvedilol (beta blocker-medication used to treat high blood pressure and heart failure). This placed R18 at risk of unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R18 documented diagnosis of hypertension (HTN - elevated blood pressure), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated 01/25/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 63 residents. The sample included 17 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 15. The facility also failed to follow physician ordered parameters for R18's antihypertensive beta-blocker (class of medication used to treat high blood pressure). This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents. Findings included: - R15's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax…

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

The facility identified a census of 63 residents. The sample included 17 residents with three reviewed for dietary preferences. Based on observation, record review, and interviews, the facility failed to follow Resident (R)26's cultural dietary preferences. This deficient practice placed R26 at risk for decreased psychosocial wellbeing and weight loss. Findings Included: - The Medical Diagnosis section within R26s Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R26's Quarterly Minimum Data Set (MDS) dated 08/22/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted she required set-up assistance from meals. The MDS noted no weight loss or swallowing disorders. R26's Nutritional Care Area Assessment (CAA) completed…

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 53 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to handle linens appropriately in order to reduce transmission of infectious diseases when the facility failed to cover clean laundry while delivering to resident rooms, and wear protective equipment (gown) when sorting soiled linens. The facility further failed to ensure appropriate use of cleaning products and techniques for disinfection of clostridioides difficile (C-Diff- a bacterium that causes diarrhea and inflammation of the colon which can be life-threatening) rooms which placed the residents and staff at increased risk for infection. Findings included: - On 03/02/22 at 02:11 PM, observation revealed Housekeeping Staff V rolled an uncovered cart with clean, folded, and hanging clothes to resident rooms. On 03/02/22 at 02:22 PM during inspection of the facility's laundry area, Housekeeping Staff V explained she wore gloves and no gown while sorting of the soiled laundry. She further stated she had not been informed of a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 53 residents. The sample included 14 residents. Based on record review and interview, the facility failed to develop a baseline care plan for one sampled resident, Resident (R) 50, upon admission. This placed the resident at risk for inappropriate care. Findings included: - The Electronic Medical Record (EMR) for R50 recorded diagnoses of type 2 diabetes mellitus (when a body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and malignant neoplasm of lower inter quadrant of the left breast (breast cancer). R50's EMR recorded the resident was admitted to the facility on [DATE]. R50's EMR lacked documentation a baseline care plan was developed upon admission to the facility. The Nurse's Note, dated 01/14/22 at 12:27 PM, documented R50 had been living at home with home health services and had become weak and required more assistance.…

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 53 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 39, who had a fluid restriction related to his dialysis (the process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform). This placed R39 at risk of complications related to fluid overload or dehydration. Findings include: - R39's diagnoses include end stage renal disease (ESRD), dependence on renal (kidney) dialysis, polycystic kidney disease (noncancerous sacs of fluid on the kidneys that lead to need of dialysis), obesity (condition of being overweight), and anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set, dated 02/09/22, recorded R39 had intact cognition, required supervision to extensive assistance with activities of daily living, on a therapeutic diet, and received dialysis. The Nutritional Care Area Assessment (CAA), dated 07/27/21, recorded…

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 53 residents. The sample included 14 residents, with three reviewed for skin condition not pressure related. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent skin tears for one sampled resident, Resident (R) 157, who received two skin tears during cares. This placed R157 at risk for further injury. Findings included: - The Electronic Medical Record (EMR) for R157 documented diagnoses of cerebral infarction (sudden loss of circulation to an area of the brain that results in an acute loss of cerebral function), hemiplegia (paralysis of one side of the body) and displaced fracture of the later malleolus of the left fibula (broken ankle). The admission Minimum Data Set (MDS), dated [DATE], documented R157 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing and toileting. The MDS further documented the resident did not have any skin issues. The Skin Integrity…

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 53 residents. The sample included 14 residents with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to complete a discharge summary for Resident (R) 49 that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed R49 at risk for miscommunication or interruptions in the continuum of care after discharge. Findings included: - R49's medical record revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) was not completed for R49. The Discharge Care Plan, dated 01/19/22, directed staff to establish a pre-discharge plan with R49 and care giver and to evaluate and revise the plan as needed as the resident wished to return to home. R49's admission Social Service Assessment, dated 01/21/22, documented the resident had a care giver at home and the resident planned to discharge to home…

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 53 residents. The sample included 14 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to use alternative communication methods for one sampled resident, Resident (R) 17, who had a diagnosis of cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition). This placed the resident at risk for ineffective communication and frustration. Findings included: - The Electronic Medical Record (EMR) documented R17 had diagnoses of cognitive communication deficit, cerebral infarction (sudden loss of circulation to an area of the brain that results in an acute loss of cerebral function), vascular dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling 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 had a census of 53 residents. The sample included 14 residents, with three reviewed for skin condition not pressure related. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears for one sampled resident, Resident (R) 157, who received two skin tears during cares. This placed R157 at risk for further injury. Findings included: - The Electronic Medical Record (EMR) for R157 documented diagnoses of cerebral infarction (sudden loss of circulation to an area of the brain that results in an acute loss of cerebral function), hemiplegia (paralysis of one side of the body) and displaced fracture of the later malleolus of the left fibula (broken ankle). The admission Minimum Data Set (MDS), dated [DATE], documented R157 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing and toileting. The MDS further documented the resident did not have any skin issues. The Skin Integrity Care Plan, 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 53 residents. The sample included 14 residents with one reviewed for dialysis (the process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform). Based on observation, record review, and interview, the facility failed to implement a physician ordered fluid restriction for Resident (R) 39, who had dialysis treatment. This placed R39 at risk of complications related to fluid overload or dehydration. Findings include: - R39's diagnoses include end stage renal disease (ESRD), dependence on renal (kidney) dialysis, polycystic kidney disease (noncancerous sacs of fluid on the kidneys that lead to need of dialysis), obesity (condition of being overweight), and anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set, dated 02/09/22, recorded R39 had intact cognition, required supervision to extensive assistance with activities of daily living, on a therapeutic diet, and received dialysis. The Nutritional Care Area Assessment (CAA),…

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 53 residents. The sample included 14 residents. Based on record review and interview, the facility failed to ensure medication was administered per physician orders for Resident (R) 158. This deficient practice placed the resident at risk for decreased well-being and ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R158 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory, confusion), and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R158's admission Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, and toileting. The Cognition Care Plan, dated 09/16/21, documented R158 was at risk for impaired cognitive…

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.