Azria Health Olathe

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 107 residents. The sample included 26 residents with one resident was reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 44 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R44 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included:- R44's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of contracture of the left elbow, contracture of the left hand, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and dementia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 107 residents. The sample included 26 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 24's dialysis (a procedure where impurities or wastes were removed from the blood) physician order was in his orders of the Electronic Medical Record (EMR). The facility failed to ensure R24's care plan provided interventions to direct staff and implement care and services according to the professional standards of practice in order to meet the resident's dialysis care needs. This deficient practice placed R24 at risk for missed dialysis visits and complications related to dialysis.Findings included:- R24's EMR documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow), end-stage renal disease (ESRD- a terminal disease of the kidneys), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort…

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 107 residents. The sample included 26 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to assess and identify trauma-based triggers related to R11's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R11. These deficient practices placed R11 at risk for decreased psychosocial well-being and ineffective treatment. Findings included:- R11's Electronic Medical Record (EMR) documented diagnoses of PTSD, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and hydronephrosis (a condition…

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 107 residents. The sample included 26 residents, with two reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related behavioral interventions for Resident (R) 16 to promote the resident's highest practicable level of well-being. This deficient practice placed R16 at risk for decreased quality of life, isolation, and impaired dignity.Findings Included:- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R16's Quarterly Minimum Data Set (MDS) completed 08/02/25 indicated a Brief interview for Mental Status (BIMS) score of three (severe cognitive impairment). The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 107 residents. The sample included 26 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's insulin (a hormone that lowers the level of glucose in the blood) was given before meals according to the physician-ordered parameters related to blood glucose monitoring. This deficient practice placed R25 at risk for hypoglycemia (less than normal amount of sugar in the blood), delayed treatment, and unnecessary medication complications. Findings included:- R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses hypertension (HTN high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), fracture of shaft of left tibia (the inner and typically larger of the two bones between the knee and the ankle), quadriplegia (inability to move the arms, legs, and trunk…

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 107 residents. The sample included 26 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 Residents (R) 4 and R5. This placed the resident at risk for inadequate end-of-life care. Finding Included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), epilepsy (brain disorder characterized by repeated seizures), psychosis (any major mental disorder characterized by a gross impairment in reality…

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

The facility identified a census of 102 residents. The sample included 22 residents with six residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure a dignified care environment for Resident (R)33, R62, R75, R88, and R89. The facility additionally failed to provide dignity while dining when the facility used disposable silverware and dishware during meals. This deficient practice placed the residents at risk of unnecessary embarrassment and decreased psychosocial well-being. Findings Included: - The Facility Reported Incident 2181 documented that on 08/13/23, R33 assisted emergency medical services (EMS) by holding open a door so EMS could enter the facility. The report indicated Administrative Staff B approached R33 and told R33 to move out of the way. The report indicated R33 refused to move, and Administrative Staff B used profanity towards R33. On 01/17/24 at 08:05 AM an inspection of the main dining area revealed residents ate breakfast with Styrofoam plates/cups and disposable plastic silverware. At 08:05 AM Dietary…

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 102 residents with six residents on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's pureed meals. This deficient practice placed six residents at risk for complications related to nutritional impairment. Findings Included- - On 01/22/23 at 10:15 AM Dietary Staff BB placed a tin of cooked beef and another of beef stock in the preparation area. The food processor machine had previously been used for food and had not been washed before puree use. Dietary Staff BB placed the contents of the cooked beef in the food processor and started to puree the meat. Dietary Staff BB then added beef stock to the processor without measuring to amount of liquid stock to be added. Dietary Staff then prepared a tin serving pan with non-stick spray and removed the textured mixer from the processor to the serving tray. An inspection of the mixer revealed a wet pudding-like consistency for the prepared meat. Dietary Staff BB did not review 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 102 residents with 22 residents included in the sample. The facility identified two residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 81 and R 28. This failure placed the residents at risk for impaired decision-making. Findings included: - A review of R81's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 08/17/23 and ended on 08/21/23. R81 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services. A review of R28's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 07/12/23 and ended on 09/01/23. R28 remained in the facility for custodial care. 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 102 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 47's medical record. This placed this resident's personal and confidential information at risk of being accessed by unauthorized individuals. Findings included: - Observation on 01/18/24 at 12:14 PM R47's Medication Administration Record (MAR) was left open, visible, and unattended on the medication cart outside of his room. On 01/18/24 at 12:16 PM Certified Medication Aide (CMA) R stated it was his mistake, he walked away from his medication cart and left the screen unlocked with R47's information visible. CMA R stated normally he locked the laptop screen every time he walked away from the cart. On 01/18/24 at 03:09 PM Licensed Nurse (LN) H stated the laptop screen should be locked every time the medication aide or nurse walked away from the laptop area. On 01/23/24 at 01:00 PM Administrative Nurse D stated he expected nursing staff to lock…

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 102 residents. The sample included 22 residents with three reviewed for abuse and/or neglect. Based on record review, observations, and interviews, the facility failed to identify a preventable accident for Resident (R) 18, who was dependent on staff for transfers with a Hoyer (full body mechanical lift), as an allegation of potential neglect and failed to report to the State Agency (SA) as required within the required timeframe. This placed the resident at risk for unidentified and ongoing neglect. Findings included: - The Electronic Medical Record (EMR) for R18 documented a diagnosis of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow that can be either structural or functional and allows urine to flow back into the kidneys). The admission Minimum Data Set (MDS) dated 07/21/23, documented a Brief Interview for Mental…

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

The facility identified a census of 102 residents. The sample included 22 residents. Based on record review and interview, the facility failed to provide written notification as soon as practicable to Resident (R) 58. This deficient practice had the risk of miscommunication between the facility and the resident. Findings included: - The electronic medical record (EMR) for R58 documented diagnosis of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and neuralgia (intense pain along a nerve). The Significant Change Minimum Data Set (MDS) dated 11/30/23 documented R58 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R58 had impairment on both sides of his body and was dependent on staff for all functional activities. The Functional Abilities Care Area Assessment (CAA) dated 12/07/23 documented R58 was dependent on staff for activities of daily living (ADLs) care needs including eating, oral and personal hygiene, toileting, and mobility issues. R58's Psychosocial…

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 102 residents. The sample included 22 residents with three residents reviewed for activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to provide the necessary assistance to Resident (R)62 for eating and drinking. These deficient practices placed R62 at risk of increased complications due to impaired ADL ability. Findings included: - The Medical Diagnosis section within R62's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), aphasia (condition with disordered or absent language function), major depressive disorder (major mood disorder), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin or the body cannot respond to the insulin). R62's Quarterly Minimum Data Set (MDS) completed 01/03/24 indicated a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. 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 102 residents. The sample included 22 residents with one resident reviewed for hydration. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for fluid overload for Resident (R) 38. This deficient practice placed R38 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R38's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R38 was dependent on staff assistance 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.

The facility documented a census of 102 residents. The sample included 22 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accidents when staff failed to correctly place the loop of the sling during a Hoyer lift (total body mechanical lift used to transfer residents) transfer which resulted in resident (R)18's fall to the floor from the lift. The facility further failed to ensure Dycem (non-slip mat used for stabilization and gripping to prevent slipping) was placed correctly in R75's wheelchair. These deficient practices placed R18 and R75 at risk for avoidable injuries. Findings included: - The Electronic Medical Record (EMR) for R18 documented a diagnosis of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow that can be either structural or…

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

The facility identified a census of 102 residents. The sample included 22 residents with four reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 18's catheter bag (urine collection bag) was kept below his bladder during a Hoyer (full body mechanical lift) transfer. This deficient practice placed R18 at increased risk for infection and other catheter-associated complications. Findings included: - The Electronic Medical Record (EMR) for R18 documented a diagnosis of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow that can be either structural or functional and allows urine to flow back into the kidneys). The admission Minimum Data Set (MDS) dated 07/21/23, documented a…

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

The facility identified a census of 102 residents. The sample included 22 with three reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide appropriate dementia care and services to address Resident (R)60's wandering behavior. This deficient practice placed R60 at risk for decreased quality of life due to the inability to maintain her highest practicable level of functioning. Findings included: - The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia, cognitive-communication disorder, dysphagia (difficulty swallowing), and major depressive disorder (major mood disorder). R60's Annual Minimum Data Set (MDS) completed 10/09/23 noted a Brief Interview for Mental Status (BIMS) score of two indicating severe cognitive impairment. The MDS indicated no wandering behaviors. R60's Cognitive Loss Care Area…

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

The facility identified a census of 102 residents with one kitchen and two dining areas. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food preparation, service, and storage. The facility additionally failed to ensure sanitary cleaning of kitchen service areas and equipment. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Finding Included: - On 01/17/24 at 08:03 AM an inspection of the facility's kitchen was completed. An inspection of the microwave oven revealed dried food residue on the top and back walls of the inside of the microwave. The kitchen's deep fryer contained dark brownish oil covered with old food debris all over the inside and outside the frying unit. A five-gallon bucket filled with used oil and old food debris under the kitchen's convection oven. An inspection of the kitchen's clean equipment storage area revealed saucers and water pitchers stored upward and uncovered on the rack. An inspection of the kitchen's reach-in…

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 102 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure staff followed appropriate infection control practices and procedures when Resident (R)88's oxygen tubing and nasal cannula (a hollow tube used to deliver supplemental oxygen) were left on the floor. The facility further failed to ensure nursing staff appropriately sanitized a community-used Hoyer (total body mechanical lift) after each use. This deficient practice placed the residents at risk related to infectious diseases. Findings included: - On 01/17/24 at 08:49 AM R88's portable oxygen tank was on the back of her wheelchair and the oxygen tubing and nasal cannula attached to the tank laid on the floor in R88's room, no bag was noted. 01/17/24 11:39 AM Certified Nurse Aide (CNA) P and Certified Medication Aide (CMA) R did not clean/sanitize the Hoyer lift after use in R51's room and CNA P then wheeled the lift into R63's room. On 01/23/24 at 11:55 AM CNA M stated lifts should be cleaned after each use and/or before…

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 99 residents. The facility had one main kitchen. Based on observation, record review, and interview, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened and the food item was not placed in a sealed container/storage bag with the proper labeling and date. The facility further failed to ensure prepared pitchers of drinks were labeled and dated. This deficient practice had the potential for food borne illnesses for residents. Findings included: - The initial tour of the facility kitchen on 05/09/22 at 07:35 AM revealed the following: in dry storage area there was a bag of white cake mix that was opened and wrapped in cellophane wrap that was not labeled or dated. In the refrigerator there was a small bowl of potato salad that was uncovered, not labeled and not dated. There were seven prepared pitchers of various drinks that were not labeled or dated. The walk-in refrigerator had three trays of baked pies that were not covered, not labeled, and not dated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 99 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to notify Resident (R) 31's Durable Power of Attorney (DPOA- legal document that names a person to make healthcare decisions when the resident was no longer able to) when R31 was transferred to the hospital for change in mental status. This deficient practice had the risk for miscommunication between R31, their DPOA, and the facility. Findings included: - R31 admitted to facility on 09/16/21 and transferred to hospital on [DATE]. The Diagnoses tab of R31's Electronic Medical Record (EMR) documented heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath), chronic kidney disease (gradual loss of kidney function), cerebral infarction (cerebrovascular accident [CVA]- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture…

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 99 residents. The sample included 23 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review, and interviews, the facility failed to provide form CMS 10123, Notice of Medicare Non-Coverage (NOMNC- a notice that indicated when the resident's care was set to end from skilled nursing facility [SNF]). It includes information for how to appeal the provider 's decision to a Quality Improvement Organization for Resident's (R) 66, R56, and R71. This deficient practice placed three residents at risk for uninformed decisions. Findings included: - The Medicare NOMNC form informed the beneficiaries that are receiving skilled therapy that are eligible for expedited determination process, even if they agree with the termination of the services. The NOMNC has a section for information related to their right to appeal the decision. The facility lacked documentation staff provided R66 or their representative the NOMNC form 10123 when the resident's skilled services ended 02/27/22. 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 99 residents. The sample included 23 residents; two residents reviewed for hospitalization. Based on observations, record reviews, and interviews, the facility failed to provide a written notification of transfers to Resident (R) 63 or to her 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 services. Findings included: - R63 admitted to the facility on [DATE], discharged to hospital on [DATE], readmitted to facility on 01/19/22, discharged to hospital 02/09/22, readmitted to facility on 02/14/22, discharged to hospital 03/28/22, and readmitted to facility 04/01/22. The Diagnoses tab of R63's Electronic Medical Record (EMR) documented diagnoses of personal history of pulmonary embolism (a condition in which 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 99 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) for documentation of anticoagulant (medication used to prevent blood from thickening or clotting) use for Resident (R) 2, R76, and R94. This deficient practice had the risk for miscommunication related to anticoagulation status. Findings included: - The Quarterly Minimum Data Set (MDS) dated 01/28/22, documented R2 received anticoagulant medications seven days in the seven-day lookback period. The Orders tab of R2's Electronic Medical Record (EMR) documented an order with a start date of 11/08/21 for clopidogrel bisulfate (antiplatelet medications- works by preventing platelets [a type of blood cell] from collecting and forming clots that may cause a heart attack or stroke) 75 milligrams (mg) one time a day related to cerebral infarction (cerebrovascular accident [CVA]- sudden death of brain cells due to lack of oxygen caused by impaired blood flow…

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 99 residents. The sample included 23 residents with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to remove an discontinued or unnecessary intervention on R39's care plan. This deficient practice placed the resident at risk for ineffective or unnecessary treatments. Findings Included- -The electronic medical record (EMR) indicated the following diagnosis for R39: cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), left hand contracture (abnormal permanent fixation of a joint), muscle spasms, hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), major depressive disorder (major mood disorder), dysphagia (swallowing difficulty), and chronic pain. A review of R39's Quarterly Minimum Data Set (MDS) dated 03/25/2022 noted a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. 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 99 residents. The sample included 23 residents with five reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R) 298. This deficient practice placed the residents at risk for ineffective skin care and decreased psychosocial well-being. Findings included: -The electronic medical record (EMR) indicated the following diagnosis for R298: chronic kidney disease, type two diabetes(when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), major depressive disorder (major mood disorder), overactive bladder, insomnia (inability to sleep), retention of urine, muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), obstructive sleep apnea (disorder of sleep characterized by periods without respirations),…

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 99 residents. The sample included 23 residents, with five residents reviewed for activities. Based on observation, record review, and interviews, the facility failed to consistently provide activities for Resident (R)52. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence. Findings included: - The electronic medical record (EMR) for R52 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Annual Minimum Data Set (MDS) dated [DATE] documented R52 had a Brief Interview for Mental Status (BIMS) score of three which indicated a severely impaired cognition. R52 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 99 residents. The sample included 23 residents with five reviewed for incontinence care. Based on observation, record review, and interviews, the facility failed to implement incontinence care interventions for Residents (R) 28, R86 and R298. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R28: chronic pain, peripheral vascular disease (abnormal condition affecting the blood vessels), hypertension (high blood pressure), osteoarthrosis (degenerative changes to one or many joints characterized by swelling and pain), bipolar disorder, vascular dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), type two 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 99 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to provide care and assistance, consistent with professional standards of practice, for Resident (R)13's prosthesis, related to his preference to wear his prosthetic device and his goal to return home. This deficient practice placed R13 at risk for impaired dignity and loss of independence. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of absence of left leg below the knee, diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and peripheral vascular disease (PVD-abnormal condition affecting the blood vessels). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R13 required extensive assistance of one staff member 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.

The facility identified a census of 99 residents. The sample included 23 residents with one reviewed for pain. Based on observation, record review, and interviews, the facility failed to provide non-pharmacological pain interventions for Residents (R) 298. This deficient practice placed the residents at risk for ineffective pain management and decreased psychosocial well-being. Findings included: -The electronic medical record (EMR) indicated the following diagnosis for R298: chronic pain, chronic kidney disease, type two diabetes(when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), major depressive disorder (major mood disorder), overactive bladder, insomnia (inability to sleep), retention of urine, muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), and need for assistance with personal cares. A review of R298's 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 99 residents. The sample included 23 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 document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day for Resident (R) 71. This deficient practice placed R71 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R71's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of end stage renal (kidney) disease (a terminal disease because of irreversible damage to vital tissues…

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 99 residents. The sample included 23 residents with five reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident R36's hypertensive medication (class of medication used to treat hypertension [high blood pressure]) given outside the physician ordered parameters, and for irregularities related to bowel movement monitoring for R81. This deficient practice which had the potential of unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R36's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 99 residents. The sample included 23 residents with five reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)36's hypertensive medication (class of medication used to treat hypertension [high blood pressure]) were administered as ordered by the physician, and failed to ensure bowel monitoring for R81. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R36's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented that R36 was dependent of two staff members assistance 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.