Good Samaritan-Olathe

The facility identified a census of 123 residents. The sample included 24 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 54's hypotension (a medication that treats low blood pressure) medication Midodrine order lacked a diagnosis. The CP failed to identify and report when R54's Midodrine was administered by facility staff outside of the physician-ordered parameters. This placed R54 at risk of unnecessary medication administration and related complications. Findings included:- R54's Electronic Medical Record (EMR) documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). R54's Annual Minimum Data Set (MDS) dated 01/22/25 documented she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R54 required setup to supervision 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 identified a census of 123 residents. The sample included 24 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 54's hypotension (a medication that treats low blood pressure) medication order, Midodrine, included a diagnosis for use. The facility failed to ensure R54's physician-ordered parameter for Midodrine was followed before the medication was administered. This placed R54 at risk of unnecessary medication administration and related complications. Findings included:- R54's Electronic Medical Record (EMR) documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). R54's Annual Minimum Data Set (MDS) dated 01/22/25 documented she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R54 required setup to supervision assistance from staff. R54 received an antipsychotic (a class 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.

The facility identified a census of 123 residents. The sample included 24 residents, with five reviewed for nutritious diets. Based on observation, record review, and interviews, the facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents (R) 80 and R104. This deficient practice placed the residents at risk for risks related to impaired nutrition and weight loss.Findings included:- On 07/21/24 at 07:00 AM, a walkthrough of the facility's secured 100 Hall was completed. An inspection of the unit's kitchenette revealed that the kitchen had an oven, and a microwave included in the kitchenette. The microwave had signage that noted When heating foods in the microwave, please make use of the thermometers provided to ensure that your food reaches the safe temperature of 165 degrees. An inspection of the cabinet to the right of the microwave revealed a thermometer and a box of disposable thermometer covers. An inspection of the refrigerator revealed uncovered and labeled food plates from the previous evening's dinner on the top two shelves.…

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 123 residents. The sample included 24 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to update Resident (R) 49's plan of care to reflect the services, medication, and equipment provided to R49 by hospice. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R49. Findings included:- R49's electronic medical record (EMR) documented diagnoses of Atherosclerotic heart disease of native coronary artery (plaque buildup in and on the walls of the heart arteries) and 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). The admission Minimum Data Set (MDS) dated 06/25/25 documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The MDS documented R49 required partial to moderate assistance for showers or bathing, 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 120 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 1's representative of care plan changes and/or results. This deficient practice had the risk of miscommunication between R1, their representative, and the facility. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of heart failure (HF-a condition with low heart output and the body becomes congested with fluid), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (cerebrovascular accident [CVA]/stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, and seizures. The Significant Change Minimum Data Set (MDS) dated 11/06/24, documented a Brief Interview for Mental Status was not conducted due to R1 rarely or never understood. R1 had coughing or choking during…

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 114 residents with one kitchen and two main dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleanliness of the kitchen/dining room equipment, clean ventilation, equipment storage, hygienic serving practices, and food storage. This placed the residents at risk for food borne illness. Finding Included- - On 12/06/23 at 07:02AM an initial walkthrough of the kitchen was completed. An inspection of the air conditioning vents above the food warming station, stove/grill, food prep table, sink, and clean plates storage revealed layered debris/dust covering the vents. An inspection of the spice storage shelf revealed spilled spice particles covering the bottle and shelf. An inspection of the wet condiment shelf revealed sticky residue underneath the honey, vanilla, and vinegar bottles. An inspection of the storage area outside the kitchen revealed a buffet table with piles of clean cloth napkins covering the top of the buffet table exposed to the environment. An…

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 114 residents. Five Certified Nurse Aide's (CNA) were sampled for prevention of abuse, neglect, and exploitation training. Based on record review and interview the facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for one of the five CNAs that were sampled. This placed the residents at risk for abuse. Findings included: - Employee record review of CNA OO revealed the facility failed to provide evidence that CNA OO received the required abuse, neglect, and exploitation training. On 12/11/12 at 02:24 PM Administrative Nurse D stated she contacted CNA OO and asked him to come in and complete the required education. On 12/12/23 at 02:41 PM Administrative Nurse D stated Consultant II oversaw and tracked the compliance and education requirements/hours for the employees at the facility. Administrative Nurse D stated it was also her responsibility to make sure employees were up to date on required training. An education policy was not provided by the facility. The facility failed to provide evidence…

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 114 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure two of the five CNA staff reviewed had the required 12 hours of in-service education which included dementia (progressive mental disorder characterized by failing memory, confusion) care training. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - Review of the facility's in-service records revealed the following: CNA OO, hired on 11/30/05, had 1.75 hours of in-service in the past 12 months. Review of trainings for CNA OO for past year lacked evidence of the required education on the topic of dementia. CNA QQ, hired on 08/31/16, had 6.59 hours of in-service in the past 12 months. Review of trainings for CNA QQ for past year lacked evidence of the required education on the topic of dementia. On 12/11/12 at 02:24 PM Administrative Nurse D stated she contacted CNA OO and asked him to come in and complete the required education. On 12/12/23…

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 114 residents. The sample include 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for Resident (R) 7 and the other cognitively impaired residents who resided outside of the locked unit. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings included: - On 12/11/23 at 09:50 a group of cognitively impaired residents sat in the fireplace social area. The residents were not alerted or invited to attend the scheduled 10:00AM. The residents did not attend the planned activity event from 10:00AM to 11:00AM. On 12/11/23 at 10:00AM the facility held a Name that Christmas song activity. The activity provided snacks for the residents as they listened for the mystery Christmas songs played. At 10:33AM R7 () wheeled herself down the hall and into the activities room. R7 wheeled herself around the room and residents attending the event. R7 wheeled herself to the front of the room by the activities staff. Staff did not invite…

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 114 residents. The facility had three medication rooms and seven medication carts. Based on observation, record review and interview the facility failed to ensure accurate labeling of medications to facilitate consideration of precautions and safe administration of medications in accordance with professional standards. The facility failed to ensure safe and secure storage of medications. This deficient practice created a risk for adverse side effects and ineffective medication administration. Findings included: - On 12/06/23 during the initial tour, the Exam Room was unlocked. Inspection of the room revealed an unlocked medication refrigerator with multiple boxes of Covid-19 vaccine and multiple does of pneumococcal vaccine. The refrigerator contained one vial of opened but undated tuberculin serum The November temperature log was posted on the refrigerator and the temperatures stopped at 11/27/23 with no further evidence staff assessed temperatures after 11/27/23. There 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 114 residents. The sample included 23 residents. Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious disease. Findings included: - Observation On 12/06/23 during the initial tour, the Exam Room was unlocked. The room had a bin of hair products including clippers and a hairbrush with gray hairs in it. The brush was in with the clippers, on the counter, and was unlabeled with any resident name or room number. The desk-type chair in the exam room had short gray hairs all over the seat surface. The handwashing sink in the exam room was not equipped with paper towels for drying. Observation on 12/06/23 at 07:12 AM an unidentified staff member walked down the hall with no mask. The staff member held a piece of paper up to her face to cover her mouth and nose. Observation on 12/06/23 at 09:06 AM two sit to stand lifts and a Hoyer (total body mechanical lift) sat in the hallway and all three- of the lifts had debris…

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 114 residents. The sample included 23 residents with three residents reviewed for accommodation of needs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60 and R209 each had a call light within reach. This placed the residents at risk for impaired care. Findings included: - R60'S Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side 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) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview for 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 114 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 209 related to his bathing preferences. This deficient practice placed R209 at risk of impaired care related to uncommunicated care needs. Findings included: - R209's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, dependence on a wheelchair, dementia (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). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R209's Care Area Assessment (CAA) was in progress. R209's Care Plan dated 11/28/23 documented the resident required (specify bathing options [reclining…

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 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60's Care Plan was revised to include his use of insulin (hormone that lowers the level of glucose in the blood). This placed R60 at risk for complications related insulin use due to uncommunicated care needs. Findings included: - R60'S Electronic Medical Record (EMR), under the :Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side 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) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview…

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 114 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent bathing for Resident (R) 7 and R209. This deficient practice had the risk for poor hygiene, skin infections, decreased self-esteem and impaired dignity. Findings included: - R7's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hearing loss, intellectual disabilities, major depressive disorder (major mood disorder which causes persistent feelings pf sadness) and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE] documented a staff interview R7's long term memory was ok, short-term memory was ok and some difficulty in new situations. The MDS documented that R7 required extensive assistance of one staff member for activities of daily living (ADLs). The Quarterly MDS dated 09/08/23 documented a staff interview revealed R7's short term memory was ok, long-term memory was ok,…

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 114 residents. The sample included 23 residents with one resident reviewed for. Based on observation, record review, and interviews, the facility failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 97. This deficient practice placed R97 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R97'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), muscle weakness, need for assistance with personal care, and history of falls. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R97 required partial/moderate assistance moving from a sitting position to standing. The MDS documented R97 received a diuretic…

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 114 residents. The sample included 23 residents with seven reviewed for accidents. Based on observation, record review, and interviews, The facility failed to provide consistent Roam Alert (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) functionality checks on Residents (R) 25's Roam Alert band. This deficient practice placed the resident at risk for elopement. The facility additionally failed to prevent avoidable accidents during R33's Hoyer (full body lift) lift transfers resulting in minor injuries and failed to utilize R87's care planned Hoyer lift while transferring her to her bed resulting in a non-injury fall. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings included: - The electronic medical record (EMR) for R25 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), needs for 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 identified a census of 114 residents. The sample included 23 residents with two reviewed for incontinence management and urinary catheters. Based on observation, record review, and interviews, the facility failed to provide individualized incontinence interventions based on Resident (R)55's significant status change. The facility additionally failed to provide consistent monitoring of urinary catheter care for R101. This deficient practice placed the residents at risk for complications related to incontinence and/or urinary tract infections (UTIs). Findings Included: - The Medical Diagnosis section within R55's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), Recent fracture (Bone Break) of the left femur (large leg bone), dementia (progressive mental disorder characterized by failing memory, confusion), and cognitive communication deficit. R55's Significant Minimum Data Set (MDS) completed 11/10/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she 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 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities with Resident (R) 60's insulin (hormone that lowers the level of glucose in the blood). This placed R60 at risk for complications related to insulin use. Findings included: - R60'S Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side 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) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R60's Quarterly Minimum Data Set [MDS] dated 10/27/23 recorded a Brief Interview…

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 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60 received his insulin (hormone that lowers the level of glucose in the blood) as ordered by the physician and failed to ensure blood glucose levels outside of physician ordered parameters were reported to the physician as ordered. This placed R60 at risk for complications related to insulin use. Findings included: - R60'S Electronic Medical Record (EMR), under the Diagnoses tab, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hemiparesis/hemiplegia (weakness and paralysis on one side 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) and diabetes mellitus (DM-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 114 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review and interview, the facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for Resident (R) 47 and R202. The facility failed to ensure that R47 and R202's written plan of care included both the most recent hospice plan of care and a description of the services furnished by both the facility and hospice. This placed R47 and R202 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - The electronic medical record (EMR) for R47 documented diagnoses of sequalae of cerebral infarction (conditions produced after the acute phase of an illness or injury due to a stroke), altered mental status (-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 reported a census of 108 residents. Based on observation, record review and interview, the facility failed to store food in accordance with professional standards for food service safety, when kitchen observation revealed numerous expired food items. This placed the residents who received meals from the facility kitchen at risk for foodborne illness. Findings included: - On 02/07/22 at 08:15 AM, during initial tour of the main kitchen revealed the following items were expired: House Recipe Quick Grits (five containers, expired on 01/15/22) Thickened Cranberry Cocktail 46 ounce container (one container, expired on 01/18/22) light molasses one gallon container (three containers, expired on 12/22/17) Potato Pearls 29.3 ounce box (six boxes, expired on 11/06/21) Carnation Breakfast Essentials Pack (19 packs, expired on 09/09/21), Gelatin Mix Assorted Flavors three ounce pack (11 packs, with expiration dates of 06/2018, 07/2018, 08/2018, and 01/2021) Drink Mix Assorted Flavors 1.27 ounce pack (30 packs, with expiration dates of 12/2020 and 01/2021) Mousse Mix Assorted…

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 108 residents with 22 sampled including one reviewed for an indwelling catheter. Based on observation, interview, and record review the facility failed to promote dignity when staff failed to provide a privacy bag for the indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) drainage bag for Resident (R) 22. This placed R22 at risk for impaired dignity and psychosocial wellbeing. Findings included: - Review of 22's Physician Order Sheet documented the following diagnoses of hydronephrosis (swelling of a kidney due to a build-up of urine) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). The 05/28/21 admission Minimum Data Set (MDS) documented a staff assessment indicated long and short-term memory problem with severely impaired cognition. R22 had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/28/21 documented the resident had a permanent indwelling urinary catheter in place 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.

The facility reported a census of 108 residents with 22 sampled including one for an indwelling catheter. Based on observation, interview, and record review the facility failed to provide safe, sanitary, and hygienic catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care by allowing Resident (R) 22's indwelling catheter drainage bag to touch the floor. This placed the resident at risk for improper catheter care. Findings included: - Review of 22's Physician Order Sheet documented the following diagnoses: hydronephrosis (swelling of a kidney due to a build-up of urine) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). The 05/28/21 admission Minimum Data Set (MDS) documented a staff assessment indicated long and short-term memory problem with severely impaired cognition. R22 had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/28/21 documented the resident had a permanent indwelling urinary catheter in place on admission. The Care…

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

The facility reported a census of 108 residents with 22 sampled with three residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to provide safe and sanitary care for oxygen tubing to help prevent the development and transmission of diseases and infections for one Resident (R) 63. This placed R63 at risk for infections. Findings Included: - R63's Electronic Health Record (EHR) under the medical diagnosis tab documented the diagnosis of hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood). The 07/02/21 admission Minimum Data Set (MDS) documented R63 had a Brief Interview for Mental status (BIMS) score of 15, indicating intact cognition, with no use of oxygen noted. The 02/02/21 Care Plan documented R63 had altered respiratory status. Staff were to monitor R63 for signs or symptoms of acute respiratory insufficiency and respiratory infection. R63 had oxygen (O2) therapy, as needed (PRN). The EHR documented a Physician Order on 12/04/21 for albuterol sulfate (bronchodilator- works by relaxing 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 reported a census of 108 residents with 22 sampled including one for dialysis care. Based on observation, record review, and interview the facility failed to monitor Resident (R) 258's dialysis (procedure where impurities or wastes were removed from the blood) treatments appropriately by not sending or collecting the dialysis communication forms. This placed the resident at risk for complications and health decline. Findings include: - Review of Resident (R) 258's Physician Order Sheet documented the diagnosis of end stage (a terminal disease because of irreversible damage to vital tissues or organs) renal (kidney) disease (ESRD). The 11/29/21 admission Minimum Data Set (MDS) documented R258 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The resident required staff assistance with all her activities of daily living (ADLs) except eating which she could do with some set up help. R258 required dialysis. The 11/29/21 ADL Functional/Rehab Care Area Assessment (CAA) documented R258 had ESRD and received dialysis three…

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.