Delmar Gardens Of Overland Park

The facility identified a census of 81 residents. The sample included 21 residents. Based on record review and interviews, the facility failed to fully complete the comprehensive Minimum Data Set (MDS) assessment Section V, Care Area Assessment Summary (CAA) for Resident (R) 1, R3, R16, R17, R30, R3, R50, R52, R67, R80, R81, and R286 to include an analysis and rationale for care planning decisions. This placed these residents at risk for not accurately reflecting each resident's needs to develop an individualized comprehensive plan of care. Findings included: - R1's Annual MDS with assessment reference date (ARD) of 02/02/24 Section V Care Area Assessment (CAA) was not completed to include an analysis and rationale for care planning decisions. R3's Annual MDS with ARD of 10/10/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R16's Annual MDS with ARD of 12/23/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R17's admission MDS with ARD of 03/02/24 Section V CAA was not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 81 residents. The sample included 21 residents with three residents reviewed for accident/fall prevention. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards when staff failed to secure chemicals in a safe, locked area, and out of reach of the thirteen cognitively impaired, independently mobile residents. The facility additionally failed to utilize safe assistive techniques related to Resident (R)61's wheelchair foot pedals and safe mechanical lift transfer techniques for R17 and R30. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 03/11/24 at 07:14 AM a walkthrough of the facility was completed. An inspection of an unlocked janitor closet on the 200 hallway revealed unsecured Diversify cleaning products including heavy-duty floor cleaners, bowl and bath cleaners, and general-purpose cleaners. The closet also contained two cans of Ajax powdered…

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 81 residents. The sample included 21 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift on one cart. This placed the 16 residents with controlled substances on the cart at risk for misappropriation of medications. Findings included: - On 03/13/24 at 10:16 AM, observation on the lower-level Hall B medication cart Controlled Drug Record flow sheet lacked evidence the staff completed the narcotic reconciliation for night shifts on 02/01/24, 02/09/24, 02/10/24, ,02/11/24, 02/23/24, 02/29/24, 03/01/24, 03/03/24,03/09/24 and 03/10/24 02/23/24, 02/29/24, 03/01/24 and 03/03/24 for evening shift; 03/01/24 and 03/03/24 for day shift (sixteen times out of a possible 126 work shifts). On 03/13/24 at 10:25 AM, Licensed Nurse (LN) H stated nurses were expected to count the narcotics with another nurse each shift. LN H stated the nurse coming on duty and the nurse going off duty should ensure the narcotic count is correct. LN…

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 81 residents. The facility had one main kitchen and three dining areas. Based on observation, record review, and interview, the facility failed to ensure food was appropriately labeled and dated during storage. The facility failed to ensure tableware was stored appropriately before meal service. The facility failed to ensure dining staff handled plates in a sanitary manner. This placed the residents at risk for foodborne illness. Findings included: - On 03/11/24 at 07:15 AM the initial tour of the main kitchen revealed the walk-in freezer had an open bag of tater tots that was not labeled or dated and was not in a sealed bag. There was an opened bag that contained four or five breaded chicken breasts that were not labeled or dated. There was an opened bag of donuts that was not labeled or dated in a sealed bag. There was an opened bag of mixed vegetables that was not in a sealed bag and lacked an open date. On 03/11/24 at 07:20 AM the walk-in refrigerator had two opened bags of whipped cream that had no open date on them. Observation 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.

The facility identified a census of 81 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the disinfecting of shared equipment and the sanitary storage of respiratory equipment. The facility failed to ensure the appropriate chemicals were used to clean a clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements) isolation room and failed to post the correct type of isolation precautions for Resident (R) 236, who had a C-diff infection. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 03/11/24 at 07:26 AM revealed an enhanced barrier isolation sign was posted on Resident (R) 236's door with isolation bins that contained clean personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) in the hallway outside the door. Upon further investigation, staff verified that R236 was on isolation precautions for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents with two residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to provide care in a respectful, dignified manner for Resident (R) 286 when staff failed to place R286's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) urine collection bag inside a dignity bag and failed to provide a dignified dining experience for R16 when staff stood beside R16 while assisting with a meal. This placed the residents at risk for impaired dignity and quality of life. Findings included: - On 03/12/24 at 07:32 AM an observation revealed R286's bedroom door was open, and he rested in his bed. R286's catheter urine collection bag hung from the side of his bed and had urine in it. A catheter dignity bag hung beside R286's urine collection bag. R286's catheter bag and urine were visible from the hallway outside of his room. 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 had a census of 81 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to include Resident (R) 12 in the development and planning of the resident's care plan, which placed R12 at risk of impaired care and autonomy. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (inadequate supply of oxygen), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), anxiety (a feeling of fear, dread, and uneasiness), seasonal allergic rhinitis (allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), morbid obesity(excessive body fat), and Covid- 19 (highly contagious respiratory…

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 81 residents. The sample included 21 residents with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)80's call light remained within his reach. The facility additionally failed to honor R12's preferences related to his bathing. This deficient practice left both residents vulnerable to impaired care and decreased autonomy. Findings Included: - The Medical Diagnosis section within R80's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), heart disease, anxiety disease, cognitive communication deficit muscle weakness, and gastroesophageal reflux disorder (GERD-backflow of stomach contents…

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 reported a census of 81 residents. The sample included 21 residents with two residents reviewed for personal property. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 81's right to private communications when R81's package was opened. This placed R81 at risk for impaired privacy and decreased autonomy. Findings included: - R81's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of lymphedema (swelling caused by the accumulation of lymph), cardiomyopathy (heart disease), congestive heart failure (a condition where the lower left chamber of the heart is not able to fill properly with blood during the diastolic phase, reducing the amount of blood pumped out to the body), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) R81's admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 14 indicating…

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 81 with 21 residents included in the sample. The facility identified seven 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) for Resident (R) 12 and R 18. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - A review of R12's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 12/13/23 and ended on 01/05/24. R12 remained in the facility for custodial care. The facility was unable to provide evidence that staff issued the SNF ABN 10055. A review of R18's EMR documented the Medicare Part A episode began on 01/02/24 and ended on 01/23/24. R18 remained in the facility for custodial care. The facility was unable to provide evidence that staff issued…

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 81 residents. The sample included 21 residents with three residents sampled for discharge. Based on observation, record review, and interview the facility failed to provide notification to the State Long-term Care Ombudsman (LTCO) for Resident (R) 43 and R16's facility-initiated transfers. The facility failed to provide written notice of transfer as soon as practicable to R43 and R16 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R43 and R16. Findings included: - The electronic medical record (EMR) for R43 documented diagnosis of cerebral vascular incident (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), hypertension (elevated blood pressure), hemiplegia and hemiparesis (muscular weakness 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents with three residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 43 and R16 and/or to their family representative when they were transferred to the hospital. This deficient practice placed the residents at risk for impaired ability to return to the facility or his same room. Findings included: - The electronic medical record (EMR) for R43 documented diagnosis of cerebral vascular incident (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), hypertension (elevated blood pressure), hemiplegia and hemiparesis (muscular weakness and paralysis of one side of the body). The Annual Minimum Data Set (MDS) dated 06/29/23 documented R43 had long and short-term memory problems. R43 had severely impaired cognitive skills 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 81 residents. The sample included 21 residents. Based on observation, record review and interviews, the facility failed to complete a comprehensive Significant Change Minimum Data Set (MDS) assessment of Resident (R) 24 after the addition of hospice services to identify needs, in order to develop an individualized comprehensive plan of care. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, confusion), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes), weakness, and hypertension (HTN-elevated blood pressure) The Annual MDS dated 03/03/23 documented that a Brief Interview of Mental Status (BIMS) should be conducted but was not done. R24's MDS documented she had not received hospice services. R24's EMR recorded a Quarterly MDS done on 07/21/23 that recorded R24…

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 81 residents. The sample included 21 residents. Based on observation, record review, and interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for Resident (R) 47's status regarding the use of a restraint. This deficient practice placed R47 at risk for inappropriate care planning and care needs. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cognitive communication deficiency, difficulty walking not elsewhere classified, and hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented that the Brief Interview of Mental Status (BIMS) was not completed. The MDS documented R47 was independent with walking during the observation period. The Quarterly MDS dated 10/23/23 documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R47 was independent with walking during the observation period. The MDS documented R47 used 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 81 residents. The sample included 21 residents with 21 residents reviewed for baseline care plans. Based on observation, record review, and interviews, the facility failed to identify Resident (R)82's required level of care assistance and her high-risk medication (Seroquel- antipsychotic medication used to treat major mental conditions that cause a break from reality) on her care plan. The facility additionally failed to complete a baseline care plan for R81. This deficient practice placed both residents at risk for preventable falls and injuries due to uncommunicated care needs. Findings included: - R82 admitted to the facility on [DATE]. The Medical Diagnosis section within R82's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), fracture (bone break) of the right femur (large leg bone), insomnia (difficulty sleeping), and history of falls. R82's admission Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81. The sample included 21 with 21 reviewed for comprehensive care plans. Based on observation, record review, and interview, the facility failed to develop comprehensive care plans for Resident (R)80, R30, and R81. The deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: -R80 admitted to the facility on [DATE]. The Medical Diagnosis section within R80's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), heart disease, anxiety disease, cognitive communication deficit muscle weakness, and gastroesophageal reflux disorder (GERD-backflow of stomach contents to the esophagus). R80's admission Minimum Data Set (MDS) dated [DATE] noted a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents with 21 residents reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)61's plan of care to include her spironolactone medication (diuretic- medication to promote the formation and excretion of urine) and R24's plan of care to include her Eliquis medication (anticoagulant- used to treat and prevent blood clots). The facility additionally failed to revise R52's Care Plan to include her ordered left-hand splint. The deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: - R61 admitted to the facility on [DATE]. The Medical Diagnosis section within R61's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational…

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 81 residents. The sample included 21 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide the necessary assistance with personal hygiene for Resident (R) 30. This deficient practice placed R30 at risk for poor hygiene, decreased self-esteem, and impaired dignity. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, history of traumatic brain injury, hypertension (HTN-elevated blood pressure), chronic pain, myalgia (muscle pain), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented required partial to moderate assistance with personal hygiene during the observation period. The Quarterly 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 81 residents. The sample included 21 residents with five residents reviewed for quality of care. Based on observation, record review, and interview, the facility failed to provide services to maintain Resident (R) 31's highest practicable level of physical function and promote comfort. The facility further failed to implement the protective sleeve (sleeve used to protect the skin on the arms and legs against damage caused by friction and shearing) to R67's right arm per the order and care plan. This deficient practice placed R31 at risk for increased impairment, pain, and contractures (abnormal fixation of a joint or muscle) and placed R67 at risk for skin injury. Findings included: - R31's Electronic Medical Record (EMR) documented a diagnosis of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (a progressive mental disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)80's low air-loss mattress pump was set to a tolerable comfort level and correct for his current weight. The facility additionally failed to utilize pressure-relieving boots for R30. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R80's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary…

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 81 residents. The sample included 21 residents with five residents reviewed for position, and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 52's splint was applied as directed, to prevent an avoidable reduction of range of motion (ROM) and/or mobility of her left hand. This deficient practice left R52 at risk for further decline and decreased ROM or mobility. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and contracture (abnormal permanent fixation of a joint or muscle) of the left hand. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which…

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 81 residents. The sample included 21 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to provide adequate respiratory care and services for Resident (R)12 when staff failed to ensure orders to clarify settings and failed to ensure sanitary storage for R12's respiratory equipment. This placed R12 at an increased risk for respiratory infection and complications. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (inadequate supply of oxygen), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), anxiety ( a feeling of fear, dread, and uneasiness),…

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 81 residents. The sample included 21 residents of which two residents were reviewed for pain. Based on observation, record review, and interview the facility failed to recognize, evaluate, manage, and treat the underlying cause of pain for Resident (R) 286. This deficient practice resulted in unmanaged pain which also placed the resident at risk for impaired mobility and diminished quality of life. Findings included: - R286's Electronic Medical Record (EMR) documented that R286 had 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 the left non-dominant side. The Significant Change in Status Minimum Data Set (MDS), dated 01/18/24, documented R286 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented no presence of pain on the pain…

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 81 residents. The sample included 21 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 1 and R16's medications lacked an indication for use. The deficient practice placed the residents at risk of unnecessary medication administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R1 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to identify Resident (R) 1 and R16's medications lacked an indication for use. The deficient practice placed the residents at risk of unnecessary medication administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R1 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). 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 81 residents. The sample included 21 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure Resident (R) 16's psychotropic (alters mood or thought) medications had an indication for use. The deficient practice placed the residents at risk of unnecessary medication administration and adverse side effects. Findings included: - R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of senile degeneration of the brain, dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and hypertension (HTN-elevated blood pressure). R16's Annual Minimum Data Set (MDS) dated [DATE] documented per staff assessment, R16 had moderately impaired cognition. The MDS documented R16 received insulin (hormone that lowers the level 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 81 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to provide and serve food substitutions that accommodated Resident (R) 3's preferences. This placed the resident at risk for impaired autonomy and decreased quality of life. Findings included: - R3's ordered diet dated 10/07/22 was a regular diet. R3's Care Plan last revised on 12/24/23 directed staff to allow the resident to make her own choices at meals. At this time R3 declined to make any adjustments to her diet. An 08/03/23 physician's Progress Note for R3 documented resident verbalized frustrations that the facility offered no diabetic diet, and that the meals were high in carbohydrates. The physician recommended and encouraged R3 to follow a no-concentrated sweets diet. A review of resident council minutes from May 2023 revealed the request for diabetic cookies. A review of resident council minutes from 2023 revealed in August 2023, residents made the complaint that low-carbohydrate foods had been requested. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 81 residents. The sample included 21 residents with five residents reviewed for immunizations. Based on record review and interview the facility failed to ensure that Resident (R) 16 and R82 were offered and educated regarding the Prevnar 20 (PCV20) pneumococcal (type of bacterial infection) vaccination or assessed by the physician to determine if contraindicated as recommended by the Centers for Disease Control and Prevention (CDC). This deficient practice placed these residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings included: - R16's immunization record in the EMR documented she had received a pneumococcal vaccination on 09/11/14 and 04/13/19. The facility lacked evidence the resident was assessed for appropriateness, offered, and educated regarding the PCV20. R61's immunization record in the EMR lacked documentation of any pneumococcal vaccinations being received or offered since admission on [DATE]. R82's…

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

The facility had a census of 88 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to follow-up or resolve resident grievances. This deficient practice placed residents at risk for unresolved concerns. Findings included: - On 09/14/22 at 10:00 AM, during private discussion with the residents of the resident council, residents verbalized an ongoing and unpleasant experience due to a resident who was disruptive and threatening toward the residents residing in the facility. Council members verbalized there had been no resolution from the facility regarding the council's grievance. Review of the resident council meeting minutes for the past year revealed grievances that were never discussed with the council. The council minutes lacked documentation of the facility's action to resolve resident grievances. Review of the facility's grievance log lacked documentation of the grievances verbalized by the council. The council verbalized Resident (R) 87 hollered at other residents and was threatening to residents and 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 88 residents. The sample included 18 residents with four residents reviewed for behaviors. Based on observation, record review, and interview, the facility failure to provide the necessary behavior cares and services for Resident (R) 87 (refer to F740) affected the quality of life for R16, R35, R53, R60 who were affected by R87's behaviors. This placed the affected residents at risk for increased stress, discomfort and social isolation. Findings included: - The Physician Order Sheet, dated 09/02/22, recorded R87 had diagnoses dementia (progressive mental disorder characterized by failing memory and confusion), bipolar disorder (major mental illness that causes people to have severe episodes of high and low moods), schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmented thoughts and impaired language communication), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), obsessive-compulsive disorder (anxiety…

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 88 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to secure chemicals in a safe, locked area out of reach of the 19 cognitively impaired, independently mobile residents. This deficient practice placed the affected residents at risk for accidents. Findings included: - On 09/12/22 at 08:30 AM, observation revealed an unlocked cabinet in the spa room in the upper level of the facility. Further observation revealed a full, quart-size spray bottle which contained non-acid disinfectant. The label stated, 'keep out of reach of children, hazardous to humans and can cause eye irritation, harmful if swallowed. On 09/12/22 at 08:40 AM, Licensed Nurse (LN) G verified the spray bottle of disinfectant was not locked in the cabinet. LN G stated the disinfectant was to be in a locked cabinet. On 09/15/22 at 08:33 AM, Administrative Nurse D verified the spray bottle of disinfectant was to be stored in a locked cabinet. Administrative Nurse D verified the upper level of the facility had 19 cognitively…

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 88 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to dispose of expired Juven (therapeutic nutrition powder) and antibiotic (medication used to treat infections caused by bacteria) medication. This deficient practice had the risk for physical complications and ineffective treatment for affected residents. Findings included: - On 09/13/22 at 07:44 AM, lower level A/B medication cart had four Juven packets 0.9 ounces (oz), with an expiration date of 03/01/22. On 09/13/22 at 07:44 AM, Certified Medication Aide (CMA) S verified the Juven packets were expired and should have been disposed of. On 09/13/22 at 08:17 AM, the lower level medication room had 11 vials of amikacin sulfate (antibiotic), 500 milligram (mg)/2 milliliters (ml), expiration date of April 2022 and a box of Juven packets, expiration date of March 2022 . On 09/13/22 at 08:17 AM, Licensed Nurse (LN) I verified the amikacin vials and the Juven were expired and should have been disposed of. On 09/15/22 at 08:30 AM,…

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

The facility had a census of 88 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to follow a recipe during puree preparation for five residents who received a pureed diet. This deficient practice had the risk for altered nutritional status, unpalatable food, and unwarranted physical complications. Findings included: - On 09/13/22 at 09:58 AM, Dietary BB prepared a pureed diet. Dietary BB placed ten ounces of cooked chicken breast into a blender with one quarter cup chicken broth, blended, then emptied the chicken into a bowl. He placed eight ounces of cooked zucchini slices with four tablespoons of water into a blender, blended, and then emptied into a bowl. Dietary BB placed a dinner roll and four tablespoons of water into a blender, blended, and then emptied into a bowl. Dietary BB did not follow a puree recipe. On 09/13/22 at 10:10 AM, Dietary BB stated he was unaware he needed to follow a puree recipe. On 09/13/22 at 10:30 AM, Administrative Staff A verified dietary staff should use a puree recipe when preparing…

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 88 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for the 84 residents who received their meals from the facility kitchen. This placed the 84 residents at risk for foodborne illness. Findings included: - On 09/12/22 at 11:33 AM, Dietary CC reached into a clear plastic container of jumbled up silverware and placed residents' silverware on place settings in the dining area. Dietary CC handled some of the silverware by the eating surface while rummaging for what she needed. Dietary CC held dishes against her soiled apron while transporting them from the cabinet to the steam table. On 09/12/22 at 11:24 AM, there were several unbagged, soiled clothing protectors on the floor by the wall in the upper level dining room. On 09/12/22 at 11:27 AM, Dietary CC verified the clothing protectors were soiled and should not be on the floor. She stated she would take care of them in a minute as she continued to place paper place…

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 88 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide respect and dignity during the meal for Resident (R) 83. This placed the resident at risk for impaired psychosocial well-being. Findings included: - On 09/12/22 at 12:00 PM, observation during meal service revealed R83 seated at a dining table. Further observation revealed Certified Nurse Aide (CNA) M loudly asked R83, Do you want me to feed you? CNA M then stated loudly across the dining room to CNA N ,I will feed R83. CNA M yelled to the dietary staff, I need R83's tray, I am feeding her. On 09/15/22 at 08:33 AM, Administrative Nurse D verified the staff are to not holler across the dining room regarding feeding a resident. The facility's Resident Rights policy, not dated, documented the residents have the right to be treated with respect and dignity. The facility failed to provide dignity and respect during dining for R83, placing her at risk for an undignified experience.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 88 residents. The sample included 18 residents with four reviewed for behaviors. Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) to reflect Resident (R) 87's behaviors and as a result did not capture the affect the behaviors had on R87 and other residents. This placed the resident at risk for continued and worsened behaviors. Findings included: - The Physician Order Sheet, dated 09/02/22, recorded R87 had diagnoses dementia (progressive mental disorder characterized by failing memory and confusion), bipolar disorder (major mental illness that causes people to have severe episodes of high and low moods), schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmented thoughts and impaired language communication), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), obsessive-compulsive disorder (anxiety disorder characterized by recurrent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 88 residents. The sample included 18 residents with four residents reviewed for behaviors. Based on observation, record review, and interview, the facility failed to implement interventions in an attempt to redirect or de-escalate Resident (R) 87's behaviors as directed by her plan of care. This placed the resident at risk for continued and worsened behaviors. Findings included: - The Physician Order Sheet, dated 09/02/22, recorded R87 had diagnoses dementia (progressive mental disorder characterized by failing memory and confusion), bipolar disorder (major mental illness that causes people to have severe episodes of high and low moods), schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmented thoughts and impaired language communication), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), obsessive-compulsive disorder (anxiety disorder characterized by recurrent and persistent behaviors that…

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 88 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility the staff's failure to correctly hold or administer blood pressure medication for Resident (R) 18, as directed by the physician. This deficient practice placed R18 at risk for uncontrolled blood pressures and unnecessary medication use. Findings included: - R18's medical record included diagnoses of hypotension (low blood pressure) and hypopituitarism (deficiency of one or more of the pituitary hormones which can affect any number of your body's routine functions, such as growth or blood pressure). The Quarterly Minimum Data Set (MDS), dated 07/07/22, documented a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition. R18 required supervision for eating; limited assistance for locomotion; and extensive assistance of one to two staff for bed mobility, transfers,…

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 88 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to correctly hold or administer blood pressure medication for Resident (R) 18, as directed by the physician. This deficient practice placed R18 at risk for uncontrolled blood pressures and unnecessary medication use. Findings included: - R18's medical record included diagnoses of hypotension (low blood pressure) and hypopituitarism (deficiency of one or more of the pituitary hormones which can affect any number of your body's routine functions, such as growth or blood pressure). The Quarterly Minimum Data Set (MDS), dated 07/07/22, documented a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition. R18 required supervision for eating; limited assistance for locomotion; and extensive assistance of one to two staff for bed mobility, transfers, toileting, hygiene, and dressing. The Medication Care Plan, dated 07/12/22, directed staff to…

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

The facility had a census of 88 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to provide a stop date or a rationale for extended use for an as needed (PRN) psychotropic medication (medication used to treat moods and behaviors) for Resident (R) 2, and a stop date for a PRN antipsychotic medication (medication used to treat psychosis and other mental conditions) for R87. This placed the residents at risk for unnecessary psychotropic medications and adverse side effects. Findings included: - The Physician Order Sheet, dated 09/02/22, recorded R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), bipolar disorder (major mental illness that causes people to have severe episodes of high and low moods), and Parkinson's disease (progressive neurological disorder characterized by tremors, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated 06/05/22, recorded R2 had a Brief Interview for Mental Status…

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