Ignite Medical Resort Overland Park LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a bed hold notice with the required information to Resident (R) 13 and R56 and/or to their family representative when transferred to the hospital. This deficient practice placed R13 and R56 at risk for impaired ability to return to the facility or his same room. Findings included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated 07/28/23 documented a Brief Interview for Mental Status (BIMS) score of five 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 83 residents. The sample included 18 residents with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide assistance for Resident (R)10 and R11 during mealtimes to promote and maintain their highest practicable abilities. This deficient practice placed both residents at risk for impaired nutrition and a decline in their ADLs. Findings Included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), left-sided hemiparesis (weakness and paralysis on one side of the body), and insomnia (difficulty sleeping). R10's Quarterly Minimum Data Set (MDS) completed 06/05/24 noted a Brief Interview for Mental Status (BIMS) score of eight indicating moderate…

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 83 residents. The sample included 18 residents with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 11 and R80's bilateral lower extremities to prevent pressure ulcers. This placed R11 and R80 at increased risk for pressure ulcer development. Findings Included: -R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with 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), hypertension (HTN-elevated blood pressure, obesity, and lymphedema…

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 83 residents. The sample included 18 residents with two residents reviewed for catheters (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) 11 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent the drainage bag tubing from resting on the floor and failed to practice good hand hygiene during catheter care. These deficient practices placed R11 at risk for catheter-related complications. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack 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 83 residents. The sample included 18 residents with one resident reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care services. Based on observation, record review, and interviews, the facility failed to provide Resident (R)73 with dementia-related care and practices during her mealtimes. This deficient practice placed the R73 at risk for impaired quality of life. Findings Included: - The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), hypertension (high blood pressure), and dementia. R73's Annual Minimum Data Set (MDS) completed 05/08/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The MDS indicated…

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 90 residents. The facility identified one resident positive for Clostridium difficile (C-diff- contagious bacteria characterized by foul smelling frequent bowel movements). Based on observations, record review, and interviews, the facility failed to follow transmission-based precautions related to isolation practices for Resident (R)60 (mildly cognitively impaired resident) and failed to perform adequate infection control practices including hand hygiene practices during wound care for R4. The deficient practice placed both residents at risk for the spread of infectious diseases and delayed healing. Findings Included: - A review of the facility's Infection Control Log revealed one resident on isolation precautions for March 2023; R60 for C-Diff. A review of R60's Electronic Medical Record (EMR) revealed she was placed isolation precautions related to C-diff and started Vancomycin (strong medication used to treat resistant bacterial infections) for ten days. R60's isolation was continued on 03/17/22 due to ongoing loose stool and positive test…

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 90 residents. The sample included 18 residents with one resident reviewed for self-administration of medications. Based on observations, record reviews, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 47. This placed the resident at risk for unnecessary medication side effects and self-administration errors. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 90. The sample included 18 residents with one resident reviewed for notification of changes. Based on observation, record review and interview, the facility failed to notify Resident (R)30 and/or his family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) of a significant change in skin condition when R30 developed a pressure ulcer (a 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) during his stay at an acute hospital which was identified when R30 readmitted to the facility. This deficient practice placed the resident at risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of peripheral vascular disease (PVD - abnormal condition…

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

The facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for abuse and mistreatment. Based on observation, record review, and interviews, the facility failed to identify an allegation of abuse, and report to the State Agency, when Resident (R) 40 told the Hospice nurse he received rough treatment from staff, and the Hospice nurse then informed the facility Director of Nursing (DON). This placed the resident at risk for unidentified and ongoing abuse and /or neglect. Findings Included: - The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses of pulmonary fibrosis (scarring of the lungs), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and…

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

The facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to investigate an allegation of staff to resident abuse when Resident (R)40 reported rough treatment from direct care staff. This placed R40 at risk for ongoing and/or unidentified abuse and mistreatment. Findings Included: - The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses of pulmonary fibrosis (scarring of the lungs), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). A review of R40's Quarterly Minimum Data Set (MDS) dated 10/19/22…

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 90. The sample included 18 residents. Two sampled residents were reviewed for hospitalization. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)30 and R4 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R30 and R4. Findings included: - The electronic medical record for R30 documented diagnoses of peripheral vascular disease (PVD - abnormal condition affecting the blood vessels), hypertension (HTN-an elevated blood pressure), and heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). The Annual…

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 90 residents. The sample included 18 residents with two residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for two residents who required assistance from staff to complete the care. This deficient practice placed Resident (R) 47 and R60 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time…

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 90 residents. The sample included 18 residents. Based on observations, record review, and interviews, the facility failed to provide bowel monitoring as ordered by a physician for Resident (R) 6 who received opioid (medications used to treat pain). This deficient practice placed the resident at risk for constipation (difficulty passing stools) and physical complications. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of chronic pain syndrome and dementia (progressive mental disorder characterized by failing memory, confusion) with mood disturbance. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of ten which indicated moderate cognitive impairment. R6 required extensive assistance with two staff for bed mobility and dressing; total dependence with two staff for transfers and toileting; and supervision with setup help for eating. R6 was always incontinent (lack of voluntary control over…

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 90 residents. The sample included 18 residents with two residents reviewed for 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). Based on observation, record review, and interviews, the facility failed to ensure staff implemented infection control practices during wound care for Resident (R) 4 who received antibiotics to treat a wound infection. This deficient practice placed R4 at risk of delayed healing, ongoing infection, and worsening of her wound. Findings included: - The electronic medical record (EMR) for R4 documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow) of vertebra (bone of the spinal column) and sacral (large triangular bone between the two hip bones), pressure ulcer, hypertension (HTN- an elevated blood pressure), chronic obstructive pulmonary disease (COPD-a progressive and irreversible…

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 90 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were used for Resident (R) 67 and R11, when staff pushed residents in their wheelchairs. This deficient practice placed these residents at risk of avoidable accidents. Findings included: - On 3/16/23 at 12: 00 PM Certified Nurse Aide (CNA) O pushed R67 in a wheelchair with no foot pedals into the dining room. R67's feet slid along the floor. R67 stomped her feet onto the floor while staff propelled her forward and attempted to stop her wheelchair in the middle of the dining room. On 03/16/23 at 12:05 PM CNA N pushed R11 in a wheelchair with no foot pedals into the dining room as R11's feet slid along on the floor. On 03/20/23 at 01:59 PM Licensed Nurse (LN) G stated all residents who were in a wheelchair and pushed by staff should have foot pedals on their wheelchair to prevent a fall or injuries that could occur if they flipped out of their wheelchairs. LN G stated all the residents had foot pedals 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 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported a lack of an appropriate diagnosis for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) medication usage. The facility failed to ensure the CP identified and reported the lack of laboratory monitoring for R6 who was on Depakote (medication used to treat seizures) for two years, antihypertensive (medications used to treat high blood pressure) medication given outside parameters for R6, a lack of dosing instructions for Voltaren (topical pain reliever medication) gel for R6, and a lack of a 14-day stop date for a PRN (as needed) antianxiety (class of medications that calm and relax people with excessive…

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 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to provide bowel monitoring for Resident (R) 47, who received opioid (medication used to relieve pain) medications; failed to ensure antihypertensive (medications used to treat high blood pressure) medications were not given outside of parameters for R6; failed to provide laboratory monitoring for R6 who received Depakote (medication used to treat seizures) for two years, and failed to ensure Voltaren (topical pain reliever medication) gel had dosing instructions for R6. This deficient practice had the risk for unnecessary medication use and unwarranted physical complications for the affected residents. Findings included: - R47's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R)47 and R65 had an appropriate diagnosis for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) medication use and failed to ensure an as needed (PRN) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication had a 14-day stop date for R6 and R142. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents. Findings included: - R47's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional…

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 96 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify blood sugar levels for Resident (R) 60 out of physician ordered parameters, monitor blood pressures and pulses for R73, and monitor bowel movements for R21, R87, R73, and R90. Findings included: - R60's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) and no behaviors. The MDS documented R60 transferred and walked without staff assistance, and received insulin injections seven days a week. The Diabetic Care Plan, dated 06/29/21, directed staff to check R60's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 96 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor blood sugars for Resident (R) 60, bowel movements for R21, R73, R87, and R90, and blood pressures and pulses for R73. Findings included: - R73's Physician Order Sheet (POS), dated 06/28/21, documented diagnoses of congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and cardiomyopathy (heart disease). R73's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required extensive assistance of one staff for all activities of daily living (ADLs) except eating, which she was independent. The MDS recorded the resident received antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality…

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

The facility had a census of 96 residents. The sample included 20 residents. Based on observation and interview, the facility failed to identify and remove expired medications in one of three medication rooms. Finding included: - On 07/27/21 at 08:40 AM, observation during initial tour of the facility revealed the B Hall medication room contained one bottle of Calcium 600 milligrams (mg) 150 tablets with an expiration date of 06/2021 and two bottles of Children Ibuprofen Oral Suspension 120 milliliters (ml) with expiration date of 05/2021. On 07/27/21 at 08:41 AM, Administrative Nurse E verified the Calcium tablets expired 06/2021 and Children's Ibuprofen expired 05/2021. Administrative Nurse E removed and disposed the items and stated expired medications should not be left in the medication room for use. The facility's Labeling of Medication Containers policy, dated August 2021 documented medications maintained in the community shall be properly labeled in accordance with state and federal regulations. Expired medications to be destroyed per protocol for medication destruction,…

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 96 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to notify the physician of elevated blood sugar levels outside the physician ordered parameters for one of five sampled residents, Resident (R) 60. Findings included: - R60's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) and no behaviors. The MDS documented R60 transferred and walked without staff assistance, and received insulin injections seven days a week. The Diabetic Care Plan, dated 06/29/21, directed staff to check R60's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood), and notify the physician of abnormal blood sugars and changes in condition. The Physician's Order, dated 02/28/21, directed staff to check R60's blood…

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 96 residents. The sample included 20 residents, with six 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 observation, record review, and interview, the facility failed to consistently complete wound treatment as ordered for three of six sampled residents, Resident (R) 62, R90, and R64. Findings included: - R62's admission Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, locomotion on and off the unit, limited staff assistance with personal hygiene, and supervision with eating. The MDS documented the resident had one unhealed Stage I (intact skin with nonblanchable redness of a localized area, usually over a bony prominence) pressure…

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.