Overland Park Post Acute

The facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 09/11/24 at 11:45 AM the facility was unable to provide proof of training records for agency staff. The staff reviewed were Certified Nurse's Aides (CNA) N, CNA O, and CNA P. On 09/11/24 at 02:40 PM Administrative Nurse D stated the facility did not keep records for the agency staff onsite. She stated the facility required the agency company to track their training and the facility did not verify or keep on record the agency staff's training or in-services. The facility was unable to provide the required training records as requested on 09/11/24. The facility's In-Service Training- All Staff policy (undated) indicated all staff were required to participate in regular in-service education. The policy noted agency or contractual staff were required to participate in orientation and annual in-service…

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 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 09/11/24 at 11:45 AM the facility was unable to provide proof of training records for agency staff. The staff reviewed were Certified Nurse's Aides (CNA) N, CNA O, and CNA P. On 09/11/24 at 02:40 PM Administrative Nurse D stated the facility did not keep records for the agency staff onsite. She stated the facility required the agency company to track their training and the facility did not verify or keep on record the agency staff's training or in-services. The facility was unable to provide the required training records as requested on 09/11/24. The facility's In-Service Training- All Staff policy (undated) indicated all staff were required to participate in regular in-service education. The policy noted agency or contractual staff were required to participate in orientation and annual in-service…

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 87 residents. The sample included 20 residents. Based on interviews and record reviews, the facility failed to provide activities on the weekends that met the residents' interests, social needs, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life. Findings included: - A review of the facility's Activity Calendar for July, August, and September 2024 was completed. The review revealed the residents were only offered self-led activities in August and September on Saturdays and Sundays. The calendar revealed there were no structured or group activity opportunities on the weekends. On 09/10/24 at 03:01 PM, the Resident Council reported the facility frequently did not provide activities on Saturdays and Sundays. The Council indicated there was no available staff to direct or assist with activity on the weekend. On 09/10/24 at 01:05 PM Activities Staff Z stated she worked Monday through Friday. She stated she had an assistant who provided activities and mail on weekends, but he no longer worked…

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 87 residents. The sample included 20 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a medication regimen review (MRR) was completed at least monthly for Resident (R) 31, R79, R28, R39, and R50. The facility further failed to ensure the Consultant Pharmacist (CP) identified and made recommendations for a Center for Medicaid and Medicare (CMS) approved indication or a gradual dose reduction (GDR) for antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications for R31 and R28. The facility failed to ensure the CP identified and reported R79 and R28's diclofenac (Voltaren- a topical medication that reduces pain and inflammation) lacked a dosage. The facility failed to ensure the CP identified and reported R39's antihypertensive (a class of medication used to treat high blood pressure) medication was given…

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 87 residents. The sample included 20 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R)44's built-up utensils (foam grip on regular utensils), and a divided plate was provided. This deficient practice left R44 vulnerable to unmet care needs due to the inability to feed herself. Findings included: - R44's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), obesity due to excess calories, hypertension (HTN-elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), anxiety (mental or emotional reaction…

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 87 residents. The sample included 20 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interviews, the facility failed to provide form CMS-10055, Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) which included the estimated cost for continued services for skilled services to the resident or their representative for Resident (R) 18, R33, and R39. This deficient practice placed three residents at risk for uninformed decisions. Findings included: - A review of R18's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 03/26/24 and ended on 05/03/24. R18 remained in the facility for custodial care. The facility issued R18 form CMS-R-131 that lacked the cost of continued therapy instead of the required CMS-10055. A review of R33's EMR documented that the Medicare Part A episode began on 02/24/24 and ended on 03/19/24. R33 remained in the facility for custodial care. The facility issued R33 form…

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 87 residents. The sample included 20 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notice of transfer/discharge as soon as practicable for Resident (R) 39's facility-initiated transfers. This deficient practice placed R39 at risk of uninformed choices and miscommunication regarding care needs. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and sleep apnea (a disorder of sleep characterized by periods without respirations). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact…

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

The facility reported a census of 87 residents. The sample included 20 residents with 20 reviewed for Minimum Data Set (MDS) completion. Based on interviews and record review, the facility failed to complete a quarterly assessment no more than 92 days from the last MDS for Resident (R)84 and R17. This deficient practice placed the residents at risk for unidentified and unmet care needs. Findings included: - A review of R84's Electronic Medical Record (EMR) revealed she had an admission MDS completed 04/30/24 with the next quarterly assessment reference date (ARD) set as 07/31/24. R84's EMR indicated a Quarterly MDS was started on 07/26/24 but never completed. The EMR indicated the MDS was In Progress. R84's EMR indicated no completed and accepted MDS assessments since 04/30/24. A review of R17's EMR revealed he had a Quarterly MDS completed 04/19/24 with the next quarterly ARD set as 07/19/24. R17's EMR indicated his Quarterly MDS was started on 07/19/24 but never completed. The EMR indicated the MDS was In Progress. R17's EMR indicated no completed and accepted MDS assessments…

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 87 residents. The sample included 20 residents with seven residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for Resident (R) 44 who required assistance from staff to complete the care. This deficient practice placed resident R44 at risk for complications related to poor hygiene and impaired dignity. Findings included: - R44's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), obesity due to excess calories, hypertension (HTN-elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), anxiety (mental or emotional reaction 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 87 residents. The sample included 20 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 interviews, record review, and observations, the facility failed to ensure Resident (R) 37, and R26s' low air-loss mattress pump, used to prevent pressure ulcers, was set and functioning for adequate pressure relief. This deficient practice placed the residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R37's Electronic Medical Records (EMR) noted diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and Parkinsonism (a slowly progressive neurologic 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 The facility identified a census of 87 residents. The sample included 20 residents with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)26, R50, and R9 were provided the services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle). This deficient practice placed the residents 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: - R26's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of lack of coordination, restlessness and agitation, hypertension (HTN-elevated blood pressure), depression (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), dysphagia (swallowing difficulty), weakness, pseudobulbar affect (a neurological condition that causes people to experience uncontrolled 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 87 residents. The sample included 20 residents with one sampled resident reviewed for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for dialysis care and services regarding Resident (R) 67's health status with each procedure. The facility additionally failed to weigh R67 before his dialysis appointments on eight occasions. This deficient practice placed R67 at risk for complications related to end-stage renal failure. Findings Included: - The Medical Diagnosis section within R67's Electronic Medical Records (EMR) noted diagnoses of major depressive disorder (major mood disorder), end-stage renal failure, and muscle weakness. R67's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 87 residents. The sample included 20 residents with two residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)37 had a safety assessment for the use of side rails, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed R37 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: - The Medical Diagnosis section within R37's Electronic Medical Records (EMR) noted diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers,…

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 87 residents. The sample included 20 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure antihypertensive (medication used to treat high blood pressure) medication was administered per the physician-ordered parameters for Resident (R) 39 and the facility further failed to ensure dosing instructions for Voltaren (non-steroidal anti-inflammatory drug [NSAID]) for R28 and R79. These deficient practices placed these residents at risk for unnecessary medication use, side effects, and physical complications. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and sleep…

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 87 residents. The sample included 20 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 28, R31, and R79 had a Center for Medicare and Medicaid Services (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) or the required physician documentation. The facility further failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depressive disorder (a mood disorder that causes…

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 87 residents. The sample included 20 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 24 by hospice. This deficient practice created a risk of missed or delayed services and inadequate end-of-life care for R24. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), pain, arthritis (inflammation of a joint characterized by pain, swelling, redness, and limitation of movement), brain damage, hypertension (HTN-elevated blood pressure), epilepsy (brain disorder characterized by repeated…

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 89 residents. The sample included three residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 remained free from abuse when Certified Nurse Aide (CNA) M tried to pull the call light out of R1's hands and pulled R1 from the bed onto the floor during the struggle. This abuse placed R1 at risk of pain, injury, and ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab 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), difficulty walking, pain, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented 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.

The facility identified a census of 102 residents. The sample included five residents. Based on record review, interview, and observation, the facility failed to ensure nursing services met the standard of care when staff failed to obtain physician-ordered lab work for Resident (R)1 including lab work to monitor for serious side effects of R1's atypical antipsychotic (class of medications used to treat major mental conditions that cause a break from reality). This placed R1 at risk for impaired quality of care and adverse effects. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and dementia with behavior disturbance (a decline in cognitive abilities that impacts a person'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 112 residents. The sample included 26 residents with 12 residents reviewed for activities of daily living (ADLs). Based on observation, record review and interview, the facility failed to provide scheduled bathing for five sampled residents, Resident (R) 29, R94, R5, R31 and R101. This placed the residents at risk for poor hygiene and skin issues. Findings included: - The Physician Order Sheet, dated 11/03/22, recorded R29 had diagnoses of bipolar disorder (mental illness with both manic and depressive episodes), major depression (mental disorder characterized by long term loss of pleasure or interest in life), Post-Traumatic Stress Disorder (PTSD - anxiety disorder characterized by stressful, frightening or distressing events), and alcohol dependence with alcohol-induced dementia (persistent mental disorder marked by memory loss and impaired reasoning). The Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R29 had a Brief Interview for Mental Status score of 15…

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 112 residents. The sample included 26 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the beginning and end of daily worked shifts for three of seven medication carts. This placed residents at risk for misappropriation of medications by staff. Findings included: - On 11/30/22 at 08:10 AM, during morning medication pass observation revealed the Arcadia Medication Cart controlled drug count book lacked signatures for beginning and end of daily shifts. Review of the seven controlled drugs-count record revealed the following: Arcadia Nurse Cart 11/08/22, 11/12/22 through 11/13/22, 11/17/22, 11/19/22 through 11/20/22, and 11/27/22. Heritage Medication Cart #1 11/25/22 through 11/29/22. Heritage Medication Cart #2, 11/24/22 through 11/29/22. On 11/20/22 at 08:15 AM, Licensed Nurse (LN) MM stated the facility provided education to all the medication aides and nurses about making sure the narcotics were counted by two staff at the beginning and ending of each shift. On…

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

The facility had a census of 112 residents. Based on observation, interview, and record review, the facility failed to label insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened for Resident (R)102 and R22, failed to discard an expired insulin pen for R112, and failed to discard expired stock medications on one of two halls. This placed the affected residents at risk for ineffective medication regimen. Findings included: - On 11/29/22 at 09:30 AM, observation of Medication Cart #1 on the Post-Acute Unit revealed R112's Humulin (fast acting insulin starts to work in 15 minutes) flex pen, expired 10/10/22; R102's Aspart (fast acting insulin) flex pen lacked a date opened, and R22's Levemir (long-acting insulin) flex touch pen, lacked a date opened. Continued observation revealed the following stock medications with expiration dates, and lack of expiration date: Vitamin B12 (vitamin for red blood cell formation), 500 micrograms (mcg), 100 tablets, expired 07/22. Senna (stool softener), 8.6 mg, 100 tablets, lacked a date of expiration.…

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 112 residents. Based on observation, interview, and record review the facility failed to implement appropriate infection control practices when cleaning a clostridium difficile (C-Diff: germ that causes serious diarrhea and other problems) isolation room on one of eight resident halls, failed to ensure nursing staff performed hand hygiene between glove changes when providing wound care for Resident (R) 16, and failed to remove soiled linens and urine containers from R16's room. These deficient practices placed the residents at increased risk for infections and transmission of a communicable disease. Findings included: - On 11/30/22 at 09:52 AM, observation revealed Administrative Nurse F disinfected a bedside table in the hall, placed a drape over the table, and opened wound dressings. She covered the items with another drape, took the table into R16's room and moved his cluttered bedside table aside. Administrative Nurse F gloved, brought in the bathroom trash can as the room trash…

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 112 residents. The sample included 26 residents. Based on observation, interview, and record review the facility failed to accommodate the needs of Resident (R) 16 when staff failed to ensure access to his closet and instead, piled clothing on his bed. This placed R16 at risk for impaired comfort and decreased psychosocial wellbeing. Findings included: - R16's Electronic Medical Record (EMR) documented diagnoses of acquired absence of limb, Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow movement), and chronic pain syndrome The 5 Day Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. The MDS documented R16 demonstrated verbal and other behaviors, but no rejection of care. The MDS documented R16 required supervision for eating, bed mobility, transfers, locomotion, dressing, hygiene, and extensive assistance of one staff for toileting. 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 reported a census of 112 residents. The sample included 26 residents with nine reviewed for abuse. Based on observation, interview and record review, the facility failed to prevent the misappropriation of medications for Resident (R) 54 when R54's lorazepam (controlled substance schedule IV for anxiety) was not located in the facility's narcotic locked cabinet, or in the facility. This placed the resident at risk for ineffective /delayed treatment. Findings Included: - The Electronic Medical Record (EMR) for R54 documented diagnoses of diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness), and hypertension (high blood pressure). The Significant change Minimum Data Set (MDS), dated [DATE], documented R54 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 112 residents. The sample included 26 residents, with one reviewed for a Pre-admission Screening and Resident Review (PASARR) for individuals with mental disorders and individuals with intellectually disability. Based on record review and interview, the facility failed to ensure completion of a PASSAR for Resident (R) 101. This placed the resident at risk for unidentified care needs and services. Findings include: - R101's Physician Order Sheet (POS), dated 11/07/22, recorded the diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion,) psychotic disturbance (any major mental disorder characterized by a gross impairment in reality testing,) Schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought,) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) R101's Quarterly Minimum Data Set (MDS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 112 residents. The sample included 26 residents. Based on observation, record review and interview the facility failed to develop and implement a diabetic care plan for sampled resident, Resident (R) 8 and a dialysis care plan R215. This placed the residents at risk to not receive appropriate cares and treatments. Findings included: - The Physician Order Sheet, dated [DATE], recorded R8 had diagnoses of dementia (persistent mental disorder marked by memory loss and impaired reasoning), schizophrenia (mental disorder that affects a person's ability to think, feel and behave rationally), neurosyphilis (infection in the central nervous system that impairs brain function), and insulin dependent diabetes (body requires insulin to regulate blood sugar levels). The Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status score of nine (moderately impaired cognition) with delusions (untrue persistent belief or perception held by a person…

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 112 residents. The sample included 26 residents with six reviewed for accidents. Based on observation, record review, and interview. the facility failed to revise the care plan with interventions to prevent falls for one sampled resident, Resident (R) 5, who had multiple falls. This placed the resident at risk for further falls. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of traumatic brain injury (TBI-brain dysfunction caused by an outside force, usually a violent blow to the head), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness (decreased strength in the muscles), and difficulty walking. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, dressing, bathing and limited assistance of one staff for locomotion on and off the unit. The MDS further…

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 112 residents. The sample included 26 residents. Based on observation, record review and interview, the facility failed to obtain laboratory tests as physician ordered upon admission for two sampled residents, Resident (R) 29 and R38. This placed the residents at risk for lack of monitoring and continued or worsened health problems. Findings included: - The Physician Order Sheet, dated 11/03/22, recorded R29 had diagnoses of bipolar disorder (mental illness with both manic and depressive episodes), major depression (mental disorder characterized by long term loss of pleasure or interest in life), Post-Traumatic Stress Disorder (PTSD - anxiety disorder characterized by stressful, frightening or distressing events), and alcohol dependence with alcohol-induced dementia (persistent mental disorder marked by memory loss and impaired reasoning). The Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R29 had a Brief Interview for Mental Status score of 15 (cognitively intact)…

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 112 residents. The sample included 26 residents with six reviewed for accidents. Based on observation, record review, and interview. the facility failed to provide a safe environment and failed to implement resident centered interventions for one sampled resident, Resident (R) 5, who received a burn from a cigarette and had multiple falls. This placed the resident at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of traumatic brain injury (TBI-brain dysfunction caused by an outside force, usually a violent blow to the head), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness (decreased strength in the muscles), and difficulty walking. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, dressing, bathing and limited assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 112 residents. The sample included 26 residents with eight reviewed for nutrition. Based on observation, record review and interview, the facility failed to monitor meal and supplement intake as ordered by the physician and recommended by the Registered Dietician (RD) for an insidious (gradual with potential for harm) weight loss for one sampled resident, Residents (R) 97. This placed the resident at risk for nutritional problems and continued weight loss. Findings included: - The Physician Order Sheet, dated 11/03/22, recorded R97 had diagnoses of 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), protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body function) and anorexia (eating disorder characterized by lack of appetite and weight loss). The Quarterly Change Minimum Data Set (MDS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 112 residents. The sample included 26 residents with three reviewed for dialysis (the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, interview and record review the facility failed to communicate and collaborate care with the treating dialysis center, failed to care plan dialysis related care, and failed to provide a renal diet as ordered for Resident (R) 215. This deficient practice placed R215 at risk for inadequate care, services and treatment for a dialysis resident. Findings included: - R215's Electronic Medical Record (EMR) documented a diagnosis of end stage renal disease (ESRD- medical condition in which a person's kidneys cease functioning on a permanent basis). The admission Minimum Data Set (MDS), dated [DATE], (signed 12/02/22) documented R215 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. The MDS documented R215 had not…

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 112 residents. The sample included 26 residents with 13 reviewed for medication concerns. Based on observation, interview, and record review the facility failed to assess or notify the physician, as ordered, of blood sugars outside of physician ordered parameters for Residents (R) 35, R8, and R94. This deficient practice placed the residents at risk of inadequate control of their blood sugar without physician intervention regarding insulin (hormone which regulates the amount of glucose(sugar) in the blood). Findings included: - R35's Electronic Medical Record (EMR) documented a diagnosis of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar level). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R35 required supervision for dressing, eating, toileting, hygiene, and was independent 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 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to notify the physician of elevated blood sugars out of the physician ordered parameters for Resident (R) 8 and R94 placing the residents at risk for continued elevated blood sugars and adverse side effects. Findings included: - The Physician Order Sheet, dated 11/01/22, recorded R8 had diagnoses of dementia (persistent mental disorder marked by memory loss and impaired reasoning), schizophrenia (mental disorder that affects a person's ability to think, feel and behave rationally), neurosyphilis (infection in the central nervous system that impairs brain function), and insulin dependent diabetes (body requires insulin to regulate blood sugar levels). The Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status score of nine (moderately impaired cognition) with delusions…

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 21 residents, with ten reviewed for Activities of Daily Living (ADLs). Based on observation, record review, and interview the facility failed to provide necessary bathing to maintain appropriate grooming and personal hygiene for four of ten sampled residents, Resident (R) 43, R60, R15, and R198. Findings included: - R43's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The MDS recorded R43 was independent with transfers, toileting, dressing, walking, and staff did not provide bathing to the resident during the seven days of the observation period. The Activities of Daily Living (ADLs) Care Plan, dated 03/31/21, recorded R43 had diagnoses of Cerebrovascular Accident (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and hemiplegia (paralysis of one side 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 had a census of 96 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections on two of five halls, when housekeeping staff failed to change gloves, wash hands, and leave Betco AF 315 (disinfectant cleaner) on for the proper kill time, during cleaning of a resident's room on contact isolation for Extended spectrum beta-lactamases (ESBL- a type of enzyme or chemical produced by some bacteria) in the resident's urine. The facility staff failed to apply personal protective equipment (PPE) prior to entering the same room. Findings included: - On 04/28/21 at 11:29 AM, Certified Nurse Aide (CNA) P and CNA Q obtained gloves, but did not apply them, then entered a resident room on contact isolation on the 200 hall, without applying PPE equipment (gloves and gown according to interview below with nurse) prior to entering the room to provide the resident cares. On 04/28/21 at 11:29 AM, CNA P stated the resident was not on isolation 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 96 residents. The sample included 21 residents with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two of three sampled residents, Resident (R) 201 and R77 or their representative, the completed Notice of Medicare Non-Coverage Form (NOMNC) 10123 Centers for Medicare and Medicare Services (CMS), and the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage Form (SNF ABN) 10055. Findings included: - The Medicare Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy. The form included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. 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…

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 21 residents with one resident reviewed for discharge. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 98. Findings included: - R98's Medical Record revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated 01/13/21, documented the resident had short and long term memory problems and had modified independence for cognitive skills for daily decision making. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, toilet use, locomotion on unit, dressing, limited staff assistance with personal hygiene, and supervision with eating. The MDS documented the resident expected to be discharged to the community. The Return to Community 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 had a census of 96 residents. The sample included 21 residents with ten reviewed for Activities of Daily Living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services as care planned for three of the eight sampled residents, Resident (R23), R70, and R57. Findings included: - R23's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had no discernible consciousness and was in a persistent vegetative state. The MDS recorded R23 required total assistance of two staff with toilet use and personal hygiene. The Activities of Daily Living Care Plan, dated 04/05/21, directed two staff to provide the resident with assistance with bathing. R23's Bathing Report and bath sheets documented the resident received a bed bath on Wednesday and Saturday day shift. The February Bathing Report documented the resident received a bed bath on the following days: 02/05/21 02/07/21 02/10/21 02/11/21 02/13/21 02/17/21 Then received a bath on 03/03/21 - 13…

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 21 residents. Based on observation, record review, and interview the facility failed to provide a physician ordered external urinary catheter for one sampled resident, Resident, (R)23. Findings included: - R23's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had no discernible consciousness and was in a persistent vegetative state. The MDS recorded R23 required total assistance of two staff with toilet use and personal hygiene. The assessment also recorded the resident had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). The Activities of Daily Living Care Plan, dated 04/05/21, recorded R28 had an external condom catheter, and directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, and check tubing for kinks during routine care each shift. The care plan recorded the resident had the potential for complications…

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 21 residents with two sampled for behavioral/emotional status. Based on observation, interview, and record review the facility failed to monitor and place interventions for two residents, Resident (R) 97 and R87 with a known history for sexual/intimate behaviors/activity. Findings included: - R97's Physician Order Sheet (POS), dated 04/13/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, muscle weakness, and unsteadiness of feet. The Quarterly Minimum Data Set (MDS), dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented the resident had physical behaviors directed towards others 1-3 days and verbal behaviors directed towards others for 1-3 days of the observation period. R97's behaviors put the resident at risk for physical injury, the behaviors put…

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 21 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide the physician ordered medications for one of six sampled residents, Resident (R) 70. Findings included: - R70's Quarterly Minimum Data Set (MDS), dated 03/26//21, recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and received an antianxiety, diuretic, and antibiotic medication 7 days of the assessment. The resident also received pain medication as needed. The Behavioral Care Plan, dated 03/02/21, recorded R70 had verbally aggressive/abusive behavioral symptoms and directed staff to administer medications as physician ordered. The Medication Care Plan, dated 03/02/21, recorded R70 had an alteration in comfort due to impaired mobility, muscle spasms, and was paraplegic. The care planned directed staff to administer medications as ordered to alleviate the symptoms. The Physician's Order dated 04/29/21 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 96 residents. The sample included 21 residents with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility's Consultant Pharmacist failed to follow up with the physician and Director of Nursing on recommendations to establish individualized physician ordered blood sugar parameters for Resident (R) 22 and an inappropriate diagnosis for antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) medication administration for R12. Findings include: - R12's Physician Order Sheet (POS), dated 04/15/21 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood that can lead to personality changes), and dementia (progressive mental disorder characterized by failing memory, confusion). R12's Significant Change Minimum Data Set, dated 01/13/21, recorded the resident had short term memory loss, long term memory loss, 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 96 residents. The sample included 21 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to adequately monitor low blood sugars and notify the physician to ensure appropriate care and treatment for one of six sampled residents Resident (R) 22. Findings included: - R22's Quarterly Minimum Data Set (MDS), dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and no behaviors. The MDS recorded R22 walked independently, required staff supervision with Activities of Daily Living (ADLs), had a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to insulin), and received insulin (hormone that regulates blood sugar levels) injections seven days a week. The Diabetic Care Plan, dated 04/12/21, directed staff to monitor R22's blood sugar, administer insulin and provide treatment 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 had a census of 96 residents. The sample included 21 residents with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R) 12's olanzapine (Zyprexa), an antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) . Findings include: - R12's Physician Order Sheet (POS), dated 04/15/21 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood that can lead to personality changes), and dementia (progressive mental disorder characterized by failing memory, confusion). R12's Significant Change Minimum Data Set, dated 01/13/21, recorded the resident had short term memory loss, long term memory loss, and was severely cognitively impaired. No behaviors were documented. The resident was documented as requiring one to two staff extensive assistance for activities of daily living.…

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