Garden Terrace At Overland Park

The facility identified a census of 147 residents. The sample included 31 residents, with 31 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 46 for person-centered preferences. The facility also failed to develop a comprehensive care plan for R82 for respiratory therapy. These deficient practices placed these residents at risk for impaired care due to uncommunicated care needs. Findings included: - R46's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognitive processes), and lack of coordination. The Annual Minimum Data Set (MDS) dated 01/03/25 documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview 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 147 residents. The sample included 31 residents, with 31 residents reviewed for care plan for resident centered revisions. The facility failed to revise the care plan to include resident-centered functional abilities for Resident (R) 23. This placed the resident at risk for unmet care needs. Findings included: - R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), muscle weakness, and 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). The admission Minimum Data Set (MDS) dated 10/15/24 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R23 had no behavioral symptoms during the observation period. The Quarterly MDS dated 04/10/25 documented a BIMS score of four, which indicated severely…

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 147 residents. The sample included 31 residents, with six residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide the necessary assistance with personal hygiene for Resident (R) 46. This deficient practice placed R46 at risk for poor hygiene, decreased self-esteem, and impaired dignity. Findings included: - R46's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognitive processes), and lack of coordination. The Annual Minimum Data Set (MDS) dated 01/03/25 documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview was conducted which indicated severely impaired cognition. The MDS documented R46 required substantial 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 identified a census of 147 residents. The sample included 31 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order to apply thrombo-embolic-deterrent hose (TED hose - specialized compression stockings designed to help manage swelling of the feet/legs) in the mornings for edema (swelling resulting from an excessive accumulation of fluid in the body tissues). This deficient practice placed R90 at risk for increased edema, pain, and skin-related difficulties. Findings Included: - R90's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of pain, hypertension (high blood pressure), insomnia (unable to sleep), cognitive-communication deficit( often stems from problems with attention, memory, executive functions), history of falling, muscle weakness, hyperlipidemia ( an abnormally high concentration of fats and lipid in the blood), aphasia (condition with disordered or absent language function), chronic obstructive pulmonary disease (COPD - 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 - R122's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and muscle weakness. The admission Minimum Data Set (MDS) dated 05/08/24 documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R122 was not at risk of the development of pressure-related injuries. The MDS documented R122 had a pressure-reducing device on her bed. The Quarterly MDS dated 02/07/25 documented a staff interview was conducted and R122 had moderately impaired cognition. The MDS documented that R122 was not at risk of development of a pressure-relayed injury. The MDS documented R122 had a pressure-reducing device on her bed. R122's Pressure Ulcer Care Area Assessment (CAA), dated 05/16/24 documented she did not have 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 147 residents. The sample included 31 residents, with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 89's braces to both knees were applied. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R89's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), pain, insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), history of falling, abnormal weight loss, unsteadiness of fee, and dementia (a progressive mental disorder characterized by…

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 Citation Text for Tag 0690, Regulation FF16 [NAME], [NAME] The facility identified a census of 147 residents. The sample included 31 residents, with three sampled residents reviewed for bowel and bladder incontinence and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interview, the facility failed to ensure staff provided appropriate treatment and services to prevent potential urinary tract infections (UTI - an infection in any part of the urinary system) for Resident (R) 11 when staff failed to ensure R11's catheter bag (a urine drainage bag that collects urine from a catheter, a tube inserted into the bladder to allow urine to drain) was drained each shift and as needed. This placed R11 at risk of complications, infection, and further urinary problems. Findings included: - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized…

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 147 residents. The sample included 31 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure there was a physician indication for oxygen administration for Resident (R) 82 and failed to ensure the oxygen tubing was stored in a sanitary manner to and contamination. This placed R82 at increased risk for respiratory infection and complications. Findings included: - R82's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), abnormal findings of lung fields, and hypoxia (inadequate supply of oxygen). The Significant Change Minimum Data Set (MDS) dated 11/13/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS lacked documentation that R82 was on oxygen therapy and had 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 identified a census of 147 residents. The sample included 31 residents with one reviewed for competent staffing. Based on observation, record review, and interviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to safely provide direct care and nursing services related to Resident (R) 198's care needs. These deficient practices resulted in preventable injuries and delayed medical treatment. Findings Included: - On 05/15/25 a review of Certified Nurses Aide (CNA) Q personnel file revealed she received a Corrective Action Form on 11/04/25. The counseling form was a final notice counseling related to an injury-related accident that occurred with R198 on 11/01/24. (See Citation F600) A Skin Related Injury report #4946 completed 11/01/24 indicated R198 received a laceration to his scalp (top of head) during a transfer from his wheelchair to his bed. The report indicated he received sutures on his scalp due to a head injury. The report noted R198 was unable to explain how he got injured. The report lacked a root-cause analysis or…

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

The facility identified a census of 148 residents. The sample included 29 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 93, and R248's physician-ordered parameters were obtained and monitored prior to administration of their beta-blocker (medications that help lower blood pressure and heart rate) antihypertensive (a class of medication used to treat high blood pressure) medications. The facility failed to ensure R93's diclofenac gel (topical medication used to treat pain and inflammation) order included the required dosage amount. These deficient practices placed R93 and R248 at risk of unnecessary medication administration and related complications. Findings included: - R93's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychosis (any major mental disorder characterized by a gross impairment perception), insomnia (inability to sleep), hypertension (HTN -…

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 - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and chronic kidney disease (the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body). R11's admission Minimum Data Set (MDS) dated 02/26/25 documented R11 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R11 displayed signs and symptoms of delirium (sudden severe confusion, disorientation, and restlessness) including inattention and disorganized thinking. The MDS documented R11 was dependent on staff for all activities of daily living (ADL). The MDS documented R11 required the use of an indwelling catheter. The MDS documented R11 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 155 residents. The sample included three residents reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to ensure staff utilized resident-specific interventions for behaviors. This deficient practice created an environment that affected R1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being. Findings included: - R1 was admitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), unsteadiness on feet, generalized muscle weakness, repeated falls, and dementia with agitation. 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 155 residents. The sample included three residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received the necessary assistive care and services with ADL to maintain her highest practicable ability and promote independence. This placed R1 at risk for injury, pain, and decreased ability to perform ADL. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of displaced intertrochanteric (where the hip and thigh bone meet) fracture of the right femur (thigh bone), displaced intertrochanteric fracture of the left femur, unsteadiness on feet, muscle weakness, dementia (a progressive mental disorder characterized by failing memory, confusion), fractures of the upper end of the left humerus (upper arm bone), history of falling, restless leg syndrome, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS) dated 01/17/24…

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 153 residents. The sample included 30 residents and five Certified Nurse Aide's (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's in-service records revealed the following: CNA NN, hired 06/11/15, had 6.78 hours of in-service in the past 12 months. CNA OO, hired 01/20/17, had 8.9 hours of in-service in the past 12 months. CNA PP, hired 03/26/15, had 6.53 hours of in-service in the past 12 months. On 09/12/23 at 002:2 PM, Administrative Staff A the person who was usually responsible to track the in-service hours for CNA recently left but a new person would be starting soon. She stated in-service education was done through an online training academy and in person. The facility's Required Inservice for Nurse Aides dated 09/13/22, documented the facility must complete a…

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

The facility identified a census of 153 residents. The facility failed to ensure that staff members properly secured their hair in a hairnet when preparing and serving residents' food. The facility failed to ensure proper hand hygiene during mealtime. This placed all residents who ate food from the facility at risk for food borne illness. Findings included: - On 09/06/23 at 12:46 PM Dietary Staff CC touched her facial mask and continued to pass out lunch plates to the residents without performing hand hygiene On 09/07/23 at 10:29 AM two dietary staff wore hairnets that did not cover all enter hair while serving and preparing food in the kitchen. On 09/12/23 at 12:00 PM Certified Dietary Manager BB stated the kitchen staff's hairnet should completely cover all their hair. She said she always tried to make sure the hair was completely covered. On 09/12/23 at 12:09 PM Administrative Nurse E stated hand hygiene should be performed before entering a room/before exiting a room, after doffing dirty gloves, when leaving a resident's room, in between serving residents at meals, in between…

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 153 residents. Five Certified Nurse Aides (CNA) were reviewed for required in-service training. Based on record review and interview, the facility failed to provide CNA PP the required in-service education for dementia (progressive mental disorder characterized by failing memory, confusion) care. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - Review of trainings for CNA PP for past year lacked evidence of the required education on the topic of dementia. On 09/12/23 at 02:12 PM, Administrative Staff A stated the facility uses an online training academy for in-service education which included dementia training. She said dementia training was done yearly from staff anniversary hire) date. Administrative Staff A verified CNA PP lacked dementia education for the past 12 months and provided a completion certificate dated 09/12/23. The facility's Required Inservice for Nurse Aides dated 09/13/22, documented the facility must complete a performance review of every nurse aide once every 12 months 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 153 residents. The sample included 30 residents. Based on observation, record review, and interview, the facility failed to secure the soiled utility room, which contained a hazardous material, to be kept out of reach of cognitively impaired, independently mobile residents. The facility additonally failed to ensure staff followed care planned interventions for Resident (R)145 to prevent accidents and falls. These deficient practices placed these residents at risk for preventable accidents and injuries. Findings included: - On 09/06/23 at 08:58 AM on the [NAME] Avenue Hall an observation revealed the door to the soiled utility room was not completely closed and could be opened by only pressing on it. There was a locking mechanism on the door; however, it was not closed enough to engage the lock. The door was slightly crooked in the frame making it difficult to close. There were no staff in the immediate area at the time. An observation inside the soiled utility room revealed 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 153 residents and one resident with COVID-19 (highly contagious respiratory virus). The sample included 30 residents. The facility failed to ensure staff did appropriate hand hygiene during Resident (R) 115's catheter (tube inserted into the bladder to drain the urine into a collection bag) care. The facility failed to ensure staff wore the facility-mandated personal protective equipment (PPE- masks) appropriately. This deficient practice placed residents at risk related to infectious diseases. Findings included: - Upon initial entry to the facility on [DATE] at 07:05 AM Maintenance Staff U was not wearing a mask. On 09/06/23 at 07:17 AM Licensed Nurse (LN) G failed to perform hand hygiene after administering medications to R127. On 09/06/23 at 07:50 AM the Administrative Nurse D wore a mask without the bottom strap secured around her neck. On 09/06/23 at 07:59 AM Maintenance Staff U brought a table to the surveyors and his mask was below his nose and mouth. . On 09/12/23 at…

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

The facility identified a census of 153 residents. The sample included 30 residents. Based on observation, record review, and interview the facility failed to ensure dignified care for Resident (R) 14, R30 and R109. This placed the residents at risk for decreased self-esteem and impaired psychosocial well-being. Findings included: - On 09/12/23 at 07:45 AM R14 and R30, both assisted diners, sat in their wheelchairs at dining tables on the second floor with no staff near them. Other residents sat at dining tables and were offered drinks. At 08:16 the food cart was brought to the dining area. At 08:38 AM, R14 and R30 continued to sit at the dining table and staff still had not assisted the residents or offered fluids while the other residents in the area had already received their meal trays. At 08:45 AM R14 and R30 continued to sit unatteneded by staff while the other residnets ate. On 09/12/23 at 08:45 AM Licensed Nurse (LN) J stated typically the staff pass out trays to the residents that require little to no assistance and then the aides would sit down to assist the dependent…

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 153 residents. The sample included 30 residents with two reviewed for accommodation of needs. Based on observation, record review and interview the facility failed to provide and use foot pedals during wheelchair transports for Resident (R)17 and R45. This placed the resident at risk for preventable accidents. Findings Included: -The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of dementia, dysphagia (difficulty swallowing), muscle weakness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and history of fractures (broken bone). R17's Quarterly Minimum Data Set (MDS) completed 06/09/23 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she required extensive assistance from one staff for bed mobility, transfers, toileting, locomotion, dressing, and bathing. The MDS indicated she required supervision and setup from staff for meals. A review of R17's Dementia Care Area Assessment…

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 153. The sample included 30 residents. Based on record review and interview, the facility failed to provide a written notification of transfers with the required information to Resident (R) 3 or the durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R3. Findings included: - The electronic medical record (EMR) for R3 documented diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion), cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of left lower limb, non-pressure ulcer (an ulcer as a result from an inadequate blood supply) of left lower leg. The Annual Minimum Data Set (MDS) dated [DATE] for R3 documented R had 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 153 residents. The sample included 30 residents with four residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold notice when Resident (R) 115 was hospitalized . This deficient practice placed R115 at risk of uninformed choices. Findings included: - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of other artificial openings of urinary tract status, dementia (progressive mental disorder characterized by failing memory, confusion), and acute kidney disease (severely damaged kidneys and unable to filter blood the way they should). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R115 required extensive assistance of one staff member for activities of daily living (ADLs). R115's EMR revealed a Discharge Return Anticipated 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.

The facility identified a census of 153 residents. The sample included 30 residents with five reviewed for activities of daily living (ADLs). Based on observations, interviews, and record reviews, the facility failed to provide the required ADL assistance to Resident (R)41. The facility additionally failed to provide R41's special adaptive equipment (small-sized spoon) for her meals. This deficient practice placed R41 at risk for complications related to weight loss and physical decline. Findings Included: - The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of chronic major depressive disorder (major mood disorder), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (swallowing difficulty), and a history of falls. R41's Quarterly Minimum Data Set (MDS) completed 08/18/23 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The…

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

The facility identified a census of 153 residents. The sample included 30 residents. Based on observation, record review, and interview the facility failed to ensure staff provided the care and services as directed in the plan of care for Resident (R)41. The deficient practice placed R41 at risk preventable aspiration and respiratory illness. The facility also failed to ensure that physician-ordered tubigrips (elasticated tubular bandage used reduce swelling) were applied to R45 for skin integrity. This deficient practice put R45 at increased risk for excess fluid retention and skin integrity issues. Findings Inlcuded: - The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of chronic major depressive disorder (major mood disorder), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and a history of falls. R41's Quarterly Minimum Data Set (MDS) 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 identified a census of 153 residents. The sample included 30 residents with one resident reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement a ROM program to help maintain and prevent a potential decrease in ROM/mobility for Resident (R) 143. The facility further failed to ensure R45's righthand splint was applied to prevent contractures. This deficient practices placed these residents at risk of loss of ability to perform activities of daily living (ADLs) and development of contractures. Findings included: - R143's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of unsteadiness on feet, generalized muscle weakness, history of falling, dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, 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 153 residents. The sample included 30 residents with three residents reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 115 with an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag) and a nephrostomy tube (an artificial opening between the kidney and the skin which allows urine to drain from the body) when the facility failed to prevent the drainage bags from resting on the floor, failed to have an anchor for the catheter tubing to prevent pulling and injury, and failed to maintain the urine drainage bag below the bladder. This deficient practices placed the resident at risk for catheter related complications. Findings included: - R115's Electronic…

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 153 residents. The sample included 30 residents with one resident reviewed for pain management. Based on observation, record review, and interviews, the facility failed to recognize, assess, and treat Resident (R) 94 for pain. This placed R94 at risk of ongoing pain, impaired psychosocial wellbeing, and diminished quality of life. Findings included: - R94's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) of sacral region (large triangular bone between the two hip bones). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R94 required extensive assistance 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 153 residents. The sample included 30 residents with 30 reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on record review, interviews, and observations, the facility failed to provide dementia care and services in order attain and maintain the residents highest practicable quality of life for Residents (R)17, R41, and R45. This deficient practiced placed the residents at risk for impaired quality of life and decreased psychosocial wellbeing. Findings Included: -The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of dementia, dysphagia (difficulty swallowing), muscle weakness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and history of fractures (broken bone). R17's Quarterly Minimum Data Set (MDS) completed 06/09/23 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 153. The sample included 30 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R)133 had an inappropriate indication and lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Seroquel (antipsychotic). This deficient practice placed R133 at risk of unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record for R133 documented diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Annual Minimum Data Set (MDS) dated [DATE] documented R133 had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 153. The sample included 30 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure Resident (R)133 had an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Seroquel (antipsychotic). This deficient practice placed R133 at risk of unnecessary medication administration and possible adverse side effects. Findings included: -The electronic medical record for R133 documented diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Annual Minimum Data Set (MDS) dated [DATE] documented R133 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired…

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

The facility had a census of 111 residents. Based on observation, record review, and interview the facility failed to provide a backflow device (unwanted flow of water in the reverse direction) or a two-inch air gap for the drainage system of the kitchen ice machine, used by the 111 residents who resided in the facility. This placed the affected residents at risk to receive contaminated ice. Findings Included: - On 03/02/22 at 11:15 AM, observation revealed three white plastic drainpipes extended from the back of the ice machine and inserted into a six inch white plastic drainpipe at the floor drain. The ice machine drainage system had no backflow device or two-inch air gap. On 03/02/22 at 11:37 AM, Dietary Staff BB verified the ice machine drainage system did not have a backflow device, or two-inch air gap to prevent possible backflow of contamination into the ice supply. The facility's Preventive Maintenance - Ice Machine, policy, dated 07/19/21, directed staff to complete a monthly inspection to ensure the ice machine operational with no infection control problems to contaminate…

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 111 residents. The sample included 23 residents with 11 reviewed for accidents/falls. Based on observation, record review and interview, the facility failed to notify the physician of low blood pressures for one sampled resident, Resident (R) 57. This placed the resident at risk for continued low blood pressures and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 02/02/22, recorded R57 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (persistent mental disorder marked by memory loss and impaired reasoning), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), psychosis (any major mental disorder characterized by gross impairment in reality testing), muscle weakness and hypertension (elevated blood pressure). R57's Quarterly Minimum Data Set (MDS), dated 01/13/22, documented the resident had a Brief Interview for Mental Status (BIMS) score of six (severe cognitive impairment). The MDS documented…

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 111 residents. The sample included 23 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide the three sampled residents, Resident (R) 13, R14, and R214 (or their representative) the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123 Centers for Medicare and Medicaid Services (CMS), and R214 the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNF ABN) Form 10055 . Findings included: - The Medicare Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy. The form included detailed explanation of non-coverage and explained the appeal process. The Medicare Form 10055 informed the beneficiary that Medicare may not pay for skilled therapy services and provided a cost estimate for continued services. It explained: (1) if Medicare does not pay, the resident would be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, would be responsible for payment 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 had a census of 111 residents. The sample included 23 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 41. This placed R41 at risk for inappropriate end of life cares. Findings included: - R41's Physician Order Sheet, dated 03/01/22, revealed diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). R41's Significant Change…

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.