Shawnee Post Acute Rehabilitation Center

The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure direct care staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Findings Included: - On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following: CNA PP's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course. CNA QQ's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE and mental health courses. LN L's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses. LN NN's facility-provided credentialling file lacked documented and completed training…

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 80 residents. Based on record review and interviews, the facility failed to ensure all staff were educated on the rights of the residents and the facility's responsibility to provide proper care. This placed the residents at risk for impaired care and decreased quality of life. Findings Included: -On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following: CNA PP's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course. CNA QQ's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE and mental health courses. LN L's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses. LN NN's facility-provided…

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 80 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) reviewed for required in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA N, hired 06/07/19, had 3.50 hours of in-service education in the past 12 months. On 03/27/24 at 08:10 AM Administrative Staff A stated staff had from February through October to complete their yearly education and that the system flagged all of the staff that completed their assigned education for the year. Administrative Staff A stated CNA N's record showed their education as completed in the system and he was unsure as to why the system had reported so few hours. Administrative Staff A stated he compared CNA N's record with another CNA and found that the assigned education was not the same. Administrative Staff A further stated…

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 80 residents. The sample included 18 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift. This placed the 14 residents with controlled substances on the cart at risk for misappropriation of medications. The facility also failed to ensure Resident (R) 42's physician-prescribed medication was available from the pharmacy for administration. This placed R42 at risk for ineffective medication regimen and related complications. Findings included: - On 03/26/24 at 08:14 AM, observation on the Maple Hill One medication cart Controlled Drug Record flow sheet lacked evidence the staff completed the narcotic reconciliation for day shifts on 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/09/24, 02/10/24, 02/12/24, 02/16/24, 02/19/24, 02/23/24 02/26/24, 02/27/24, 03/01/24, 03/02/24 03/03/24, 03/04/24, 03/07/24, 03/08/24, 03/09/24, 03/15/24, 03/16/24, 03/17/24, 03/18/24, 03/22/24, and 03/25/24, for night shifts; 02/01/24,…

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

The facility identified a census of 80 residents. The facility had one main kitchen and four kitchenettes with dining areas. Based on observation and interview, the facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness, and cross-contamination (the transfer of harmful substances to food). Findings included: - Observation during the initial kitchen tour on 03/25/24 at 07:15 AM revealed in the kitchen storage freezer were two open bags of fried potatoes that had no label or date and were not in a sealed bag. The walk-in freezer unit leaked and had ice around some of the pipes. The walk-in freezer had an area of what appeared to be water that had dripped from the freezer unit and froze on the floor. Observation during the lunchtime services of food on 03/25/24 at 12:23 AM in the Maple Hills 2 dining area revealed that plates, bowls, and saucers were stored right-side up on the counter. An unidentified dietary staff…

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 80 residents. The sample included 18 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21 was treated with respect, and dignity related to personal hygiene, and the facility also failed to ensure a dignified dining experience when staff stood over R25 and R57 instead of sitting beside him while assisting them with meals. These deficient practices placed the residents at risk for negative psychosocial outcomes and decreased dignity. Findings included: - R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, and need for assistance with personal care. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of 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 80 residents with 18 residents included in the sample. The facility identified 54 residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 49 and R 336. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - R49's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/19/23 and ended on 03/09/23. R49 remained in the facility for custodial care. The facility issued SNF ABN 10055 lacked an estimated cost for continued services. R336's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/11/23 and ended on 01/03/24. R336 remained in the facility for custodial care. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 80 residents. The sample included 18 residents with two residents sampled for hospitalization and one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide written notice of transfer as soon as practicable to Resident (R) 27 and R43 or their representative for their facility-initiated transfers and/or discharge. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R27 and R43. Findings included: - The electronic medical record (EMR) for R27 documented diagnoses of hypertension (HTN- elevated blood pressure), hemiplegia and hemiparesis following cerebral infarction (paralysis and muscle weakness on one side of the body after a stroke), and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated 12/19/23 documented R27 had both short…

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 80 residents. The sample included 18 residents with three residents sampled for hospitalization and discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 43 or to their family representative when R43 was transferred to the hospital. This deficient practice placed R43 at risk for impaired ability to return to the facility or his same room. Findings include: - The electronic medical record (EMR) for R 43 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting left…

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 80 residents. The sample included 18 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R)28 and R17. This deficient practice placed the residents at risk for infections and decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion). R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of ten indicating moderate cognitive impairment. The MDS indicated he had no behaviors. The MDS indicated he used a wheelchair and was dependent on staff for mobility. The MDS indicated he had no upper or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 80 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) 57's and R36's bilateral lower extremities. This deficient practice placed these residents at risk of developing pressure ulcers and worsening of current wounds. Findings included: - R57's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 57 was provided services and treatment to prevent her contractures (abnormal permanent fixation of a joint or muscle) from worsening in her left and right hands. This deficient practice left R57 at risk for further decline and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). or mobility. Findings included: - R57's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in…

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 80 residents. The sample included 18 residents with three reviewed for falls. Based on observation, record review, and interviews, the facility failed to provide an environment free of accident hazards resulting in Resident (R)28's non-injury fall in the facility's spa room. The facility additionally failed to implement wandering interventions for R28 and failed to provide safe transferring practices for R25. These deficient practices placed both residents at risk for preventable falls and injuries. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion). R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal 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 80 residents. The sample included 18 residents with four reviewed for bowel and bladder management. Based on observations, record reviews, and interviews, the facility failed to follow standards of practice related to sanitary catheter care for Resident (R)50. This deficient practice placed R25 at risk for complication-related urinary tract infections (UTI). Finding included: - R50's Electronic Medical Record (EMR) documented a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and generalized muscle weakness. The admission /Medicare Minimum Data Set (MDS), dated 08/24/23, documented R50 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R50 required partial to moderate assistance with bathing and lower body dressing. The MDS further documented R50 had an indwelling catheter.…

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 80 residents. The sample included 18 residents with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Resident (R) 46. This deficient practice placed R46 at risk of delayed services, potential adverse outcomes, and physical complications related to dialysis. Findings included: - R46's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on renal dialysis. The Annual Minimum Data Set (MDS), dated 10/09/23, documented R46 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R46 was independent of activities of daily living (ADL) and received dialysis services. The Nutritional Status Care Area Assessment (CAA) dated 10/09/23, documented R46 was 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 identified a census of 80 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview Based on observation, record review, and interview the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R)28's Seroquel (antipsychotic medication). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing),…

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 80 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to administer Resident (R)62 ' s medications as ordered. This resulted in a medication error rate of 26.67%. Findings included: - R62's Electronic Medical Record (EMR) under Physician ' s Orders revealed the following: An order dated 12/30/23 instructing to administer 400 milligrams (mg) of Gabapentin (medication used to treat nerve pain) via an enteral (within or via the small intestine) tube each morning for neuromuscular pain. An order dated 12/30/23 instructing to administer 200 mg of Amiodarone (medication used to treat irregular heart rhythms) via enteral tube each morning for irregular heartbeat. An order dated 12/30/23 instructed to administer one tablet of Sennoside docusate (laxative) via enteral tube each morning for constipation. An order dated 12/29/23 instructing to administer 5 mg of Eliquis (medication used to prevent the 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.

The facility identified a census of 80 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17 was free from significant medication errors when staff failed to administer insulin (a hormone that lowers the level of glucose in the blood) and antihypertensive (class of medication used to treat high blood pressure) medications as ordered. This placed R17 at risk for adverse side effects and medical complications. Findings included: - The electronic medical record (EMR) for R17 documented diagnosis of hypertension (HTN-elevated blood pressure), type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R17's Annual Minimum Data Set (MDS) dated 03/24/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R17 required extensive assistance from…

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 80 residents. The sample included 18 residents with three reviewed for nutritional diets. Based on observation, record review, and interviews, the facility failed to follow Resident (R)28's specialized dietary requirements during meal services. This deficient practice placed the residents at risk for impaired nutrition and aspiration (inhaling foreign material or vomit). Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion). R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated R28 had no behaviors. The MDS indicated he used a wheelchair and was dependent on staff for mobility. The MDS indicated he had…

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 80 residents. The sample included 18 residents with three residents 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 describe the services and equipment provided to Resident (R) 21 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R21. Findings included: - R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, and need for assistance with personal care. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental…

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

The facility identified a census of 80 residents. The sample included 18 residents with two residents where on transmission-based precautions. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene, the disinfecting of shared equipment, and the replacement of respiratory equipment. The facility also failed to ensure laundry temperatures for laundry including laundry from transmission-based precaution rooms with infectious diseases were assessed for appropriate temperatures. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 03/25/24 at 10:52 AM Resident (R) 56's oxygen tubing was dated 01/03/24. R56 stated he asked staff to change the oxygen tubing and staff informed him the facility did not have long enough tubing to replace it. Observation on 03/26/24 at 08:14 AM Licensed Nurse (LN) G pushed her medication cart down the hallway and stopped at R29's room. LN G donned gloves pushed the vitals…

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 80 residents. The sample included 18 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 42, R27, and R23 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) as consented. This placed the residents at increased risk for complications related to pneumonia. Findings included: - R42's Electronic Medical Record (EMR) revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. A review of Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination form for R42 dated 10/19/23 provided by the facility revealed a signed consent to receive the pneumococcal vaccination. The form indicated R42 was provided educational information related to the vaccination but never received the PCV 20 vaccination. The facility was unable to provide evidence the PCV20 was administered to R42. R27's EMR revealed he was eligible and within the required vaccination date range to receive…

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 79 residents. The sample included three residents reviewed for grievances. Based on record review, observations, and interviews, the facility failed to log grievances received from or about Resident (R) 1 and failed to record actions taken and provide a resolution to the resident and/or representatives regarding the grievances. This deficient practice placed the residnet at risk for unresolved grievances and decreased quality of care. Findings include: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of chronic congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath); cognitive communication deficit (communication problems that have an underlying cause in a cognitive deficit- like from a stroke); generalized anxiety (a condition with exaggerated tension, worrying, and nervousness about daily life events), and depression (a mental state of low mood 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 had a census of 79 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure a system that all staff implemented for residents to file grievances . This placed residents at risk for unresolved concerns. Findings included: - Review of the resident council meeting minutes for the past year, lacked documentation residents reported grievances concerning Resident (R) 2's behaviors. Review of the facility's grievance log for the past year, lacked documentation residents reported grievances concerning R2's behaviors. The facility's Progress Note, dated 10/04/22 at 09:35 PM, recorded R2 had disruptive yelling behaviors throughout the afternoon, staff were not able to redirect the resident's behaviors, and other residents voiced complaints and threatened to call the police about R2's behaviors. The Progress Note also recorded a resident's family contacted the nurse, complained their family member was not able to sleep due to R2's yelling, and demanded a room change for their family member. On 10/03/22 at 12:28…

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 79 residents. Based on observation, record review, and interviews, the facility failed to serve food in a safe and sanitary manner for two of the five kitchenettes in the facility. This placed the affected residents at risk for food-borne illness. Findings Included: - On 10/03/22 at 08:30 AM, during tour of the facility kitchenette, observation of the temperature logs of [NAME] one and Maple two daily food temperature logs lacked evidence staff assessed temperature of the following meals: Willow one: Review of the weekly unit temperature logs from September 25 until October 1, 2022 revealed the 09/26/22 supper meal lacked documented temperatures. Review of the weekly unit temperature logs form August 28 until September 3, 2022 revealed the 09/28/22 supper meal lacked documented temperatures. Review of the weekly temperature logs from August 14 -20, 2022 revealed the 08/17/22 supper meal lacked documented temperatures. Maple two: Review of the weekly temperature logs from July 20-30, 2022 lacked temperatures of the lunch meal on 07/24/22 and the supper…

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 79 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to report Resident (R) 4's allegation of verbal, emotional, and physical abuse to State Agency (SA) as required. This deficient practice placed R4 at risk of ongoing abuse. Findings included: -The Medical Diagnosis section withing R4's Electronic Medical Record (EMR) included diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of…

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 79 residents. The sample included 19 residents of which seven were 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 implement a soft heel boot as directed by the provider to treat a facility-acquired pressure ulcer for Resident (R)71. This placed R71 at risk for further skin breakdown and delayed healing. Findings included: - R71's Physician Order Sheet dated 10/03/22, included diagnoses of anxiety (mental or emotional reaction characterized by apprehension), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cerebrovascular accident (CVA- 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 right-side hemiplegia (paralysis of one side of the body). R71's Quarterly…

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 79 residents. The sample included 19 residents with two reviewed for behaviors. Based on observation, record review and interview, the facility failed to provide the necessary behavioral health services and interventions for one of two sampled residents, Resident (R) 2. This placed the resident at risk for continued and worsened behaviors. Findings included: - The Physician Order Sheet, dated 09/02/22, recorded R2 had diagnoses of mild cognitive impairment, metabolic encephalopathy (chemical imbalance in the blood that impairs brain function), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and depression (abnormal emotional state characterized by exaggerated feelings of sadness and worthlessness). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R2 had a Brief Interview for Mental Status score of 15 (cognitively intact) and no behaviors. The MDS recorded R2 required extensive staff assistance with activities of daily…

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 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a system where staff acknowledged, reported to the physician, and acted upon the Consultant Pharmacist (CP) recommendations for Resident (R) 6 who received routine insulin (medication used to lower blood sugar). This placed the resident at risk for complications related to high or low blood sugar levels. Findings included: - R6's Medical Diagnosis section withing the Electronic Medical Record (EMR) included diagnoses of chronic pain syndrome, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic neuropathy (nerve damage) and multiple sclerosis (progressive disease of the nerve…

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 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain blood sugar parameters for Resident (R) 6 who received routine insulin (medication used to lower blood sugar). This placed the resident at risk for complications related to high or low blood sugar levels. Findings included: - R6's Medical Diagnosis section withing the Electronic Medical Record (EMR) included diagnoses of chronic pain syndrome, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic neuropathy (nerve damage) and multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6…

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 79 residents. The sample included 19 residents. Based on observation, record review , and interview, the facility failed to secure a treatment cart and appropriately store and label multiple-dose insulin (medication to lower blood sugar) pens (an injection device) located on the second-floor nursing unit for Resident (R) 59, R24 and R53. This deficient practice placed the residents at risk for ineffective medication and allowed unsafe access to medications. Findings included: - On 09/28/22 at 08:09 AM, during initial tour, observation revealed the medication cart had insulin pens which were not dated when opened for R59 and R24. On 09/28/22 at 08:25 AM, during initial tour, observation revealed an unattended treatment cart located in the hall, which was unlocked and unattended. The unlocked treatment cart drawers contained multiple insulin pens. R53's multidose insulin pen lacked a date when opened. On 09/28/22 at 08:09 AM, Licensed Nurse (LN) G verified R59 and R24 lacked opened dates on the insulin pens. LN G stated the pens should have been labeled…

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 79 residents. The sample included 19 residents. Based on observation, record review and interview, the facility failed to prepare a pureed diet using professional standards to maintain nutritive and palatable value for three residents, Resident (R)22, R23, and R52. This placed the residents at risk for inadequate nutrition. Findings included: - On 10/03/22 at 11:00 AM, observation revealed Dietary Staff (DS) CC prepared three pureed diets. DS CC placed three servings (approximately three ounces each serving) of lemon peppered chicken in a food processor/blender. DS CC blended the chicken, added an unmeasured amount of chicken broth, to the pureed texture, then emptied the chicken into three stainless-steel food storage pans, then stored the pans in the oven. DS CC placed three servings (approximately four ounces each serving) of macaroni salad in a food processor/blender. DS CC blended the macaroni salad, added one half cup of milk, then blended to the correct pureed texture, emptied the macaroni salad on to the divided plates. Continued observation…

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.