The Village At Mission

The facility identified a census of 34 residents. The sample included 14 residents with two reviewed for nutrition. Based on observation, interviews, and record review, the facility failed to provide consistent weekly weight monitoring as required by Resident (R)105's physician's orders. This deficient practice placed R105 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Findings Included: - The Medical Diagnosis section within R105's Electronic Medical Records (EMR) included diagnoses of COVID-19 (highly contagious respiratory virus), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). R105's Significant Change Minimum Data Base (MDS) completed 09/20/23 noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to severe cognitive impairment. The MDS indicated he required total assistance from one staff for meals. The MDS noted he weighed 133 pounds (lbs.) and had weight loss. The MDS noted he was…

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

The facility identified a census of 34 residents. The sample included 14 residents with one reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R)106's childhood sexual abuse and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R106 at risk for decreased psychosocial well-being and ineffective treatment. Findings Included: - The Medical Diagnosis section within R106'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), acute respiratory failure, morbid obesity (severely overweight), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety disorder (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 reported a census of 34 residents. The sample included 14 residents with six reviewed for pharmacy services. Based on observation, record review, and interviews, The facility failed to establish a system to enable accurate medication reconciliation and maintenance of Resident (R)106's controlled hypnotic medication (a class of medications used to induce sleep) records. This deficient practice placed the affected residents at risk for medication diversion and/or misappropriation. Findings Included: - The Medical Diagnosis section within R106's Electronic Medical Records (EMR) included diagnoses of congestive heart failure, acute respiratory failure, morbid obesity (severely overweight), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and insomnia (difficulty sleeping). R106's Quarterly Minimum Data Set (MDS) completed 07/25/23 noted a…

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

The facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered chest x-ray results for Resident (R) 53 were signed and scanned into the clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R53's Electronic Medical Record (EMR) under the Medication Administration Record (revealed the following physician orders: Chest X-ray two views to rule out pneumonia (inflammation of the lungs) dated 07/21/23. Chest X-ray two views due to congestion and cough 09/15/23. R53's EMR, including the Misc. tab, lacked the chest x-ray results. The facility obtained and provided a copy of R53's unsigned x-ray results upon request. On 10/25/23 at 04:22 PM Administrative Nurse D stated she expected lab and x-ray results to reviewed and scanned into the residents EMR within 24 hours but no later than 72 hours. The facility was unable to provide a policy related to medical records. The facility failed to ensure physician…

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 43 residents. The sample included 12 residents, with five 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) 9, R17, R32, R23, and R5. This placed these residents at risk for skin problems and poor hygiene. Findings included: - R9's Physician's Order Sheet, dated 02/07/22, recorded diagnoses of dementia (persistent mental disorder marked by memory loss and impaired reasoning), muscle weakness, and seizure disorder (uncontrolled brain activity that cause abnormal movements such as twitching, rigidity, limpness) The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of 12 (cognitively intact) with no behaviors. The MDS recorded R9 required extensive to total staff assistance with transfers, dressing, personal hygiene, bathing, and was incontinent of bowel and urine. The Activities 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 43 residents. Based on observation, record review, and interview, the facility failed to serve palatable food during meals that maintained appetizing temperatures for the residents who resided in the facility and received food from the facility kitchen. This placed the residents at risk for nutritional status problems and weight loss. Findings included: - The 02/09/22 lunch menu recorded club sandwich, macaroni salad, fruit cobbler, and potato/vegetable soup. On 02/09/22 at 12:30 PM, observation during the noon meal revealed staff brought the insulated food cart to the North 100 hall. At 12:45 PM staff removed the last tray out of the food cart. Upon request, Registered Dietician (RD) GG obtained a thermometer and measured the temperatures of the last tray of food on the cart for Resident (R) 5 with the following results: Cheese Pizza slice 160.0 degrees Fahrenheit (F) (the resident chose an alternate) Potato/Vegetable soup 122.5 F Macaroni pasta salad 67.9 degrees F On 02/09/22 at 09:35 AM, R5 stated her food was usually cold and late. On 02/09/22 at…

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

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 43 residents in the facility, who received their meals from the facility kitchen. This placed the residents at risk for food borne illness. Findings included: - On 02/09/22 at 08:30 AM, during initial tour, observation revealed the following in the long-term care kitchenette: 1- eighteen by eighteen-inch square air vent located above the food steam table and food serving area with brownish gray fuzzy substance on the grill and on the ceiling tiles surrounding the air grill. The refrigerator revealed one 12-ounce container of macaroni and cheese with an expiration date of 12/24/21. The food temperature logs and refrigerator/freezer/dishwasher temperatures had not been documented since February 1. On 02/09/22 at 08:40 AM, Dietary Staff (DS) BB verified the refrigerator/freezer/dishwasher temperatures had not been documented since February 1, and stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 12 residents, with two reviewed for urinary catheters. Based on observation, record review, and interview, the facility failed to ensure urinary catheter tubing and collection bag did not contact the floor for Resident (R) 8 and R18, and appropriate disinfectant cleaning of the glucometer (device used to measure blood sugar) for R138 and R86. This placed R8 and R18 at risk for urinary tract infections (UTIs) and R138 and R86 at risk for blood borne infections. Findings included: - The Physician Order Sheet, dated 02/04/22, recorded R8 had diagnoses of dementia (persistent mental disorder marked by memory loss and impair reasoning), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and a history of urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status (BIMS) score of seven (severe cognitive impairment) with no behaviors. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 12 residents, with two reviewed for urinary catheters. Based on observation, record review, and interview, the facility failed to cover urinary catheter bags for two sampled residents, Resident (R) 8 and R18. This placed R8 and R18 at risk for impaired dignity and psychosocial wellbeing. Findings included: - The Physician Order Sheet, dated 02/04/22, recorded R8 had diagnoses of dementia (persistent mental disorder marked by memory loss and impair reasoning), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and a history of urinary tract infection (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status (BIMS) score of seven (severe cognitive impairment) with no behaviors. The MDS recorded R8 required extensive staff assistance with transfers, had a urinary catheter, and used a wheelchair for mobility. The Urinary Catheter Care Plan, dated 02/09/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 12 residents with three reviewed for accident hazards. Based on observation, record review and interview, the facility failed to provide adequate supervision and assistance devices to prevent accidents for two of three sampled residents, Residents (R) 8 and 32. This placed R8 and R32 at risk for skin injuries and falls. Findings included: - The Physician Order Sheet, dated 01/28/22, recorded R8 had diagnoses of dementia (persistent mental disorder marked by memory loss and impair reasoning), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status (BIMS) score of seven (severely impaired cognition). The MDS recorded R8 required extensive staff assistance with transfers, impaired balance that required staff assistance to stabilize, history of falls, and used a wheelchair for mobility. The…

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

The facility had a census of 43 residents. The sample included 12 residents with one reviewed for dialysis. Based on observation, record review, and interview, the facility failed to provide ongoing communication and assessment of the resident's dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment, including monitoring for Resident (R) 135. This placed the resident at risk for complications and health decline. Findings included: - R135's Physician's Order Sheet, dated 01/26/22 documented the resident had diagnoses of end stage renal disease (decline in kidney function.) R135's admission Minimum Data Set (MDS), dated 02/06/22, recorded R135 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS recorded he required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS further recorded R135 was occasionally incontinent of urine and did not record the resident received dialysis…

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 43 residents. The sample included 12 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure one of five sampled residents, Resident (R) 12, received as needed (PRN) Xanax (an antianxiety medication that calm and relax people with excessive restlessness, nervousness and tension) with a 14 day stop date and rationale for use. This placed R12 at risk to receive unnecessary psychotropic medications (medications that affect the chemical make-up of the brain). Findings included: - R12's Physician's Order Sheet, dated 02/04/22, recorded diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R12 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated…

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

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure insulin (hormone that lowers the level of glucose in the blood.) pens were dated when opened for Resident (R) 2, R28, and R138. This placed the affected residents at risk for decreased medication effectiveness. Findings included: - On 02/09/22 at 08:23 AM, observation revealed insulin pens not dated when opened for the following residents: R2 - Lantus insulin pen R28 - Lantus insulin pen and Humalog insulin pen R138 - Novolog insulin pen On 02/09/22 at 08:23 AM, Licensed Nurse (LN) G stated staff marked the insulin pen with a marker that easily rubbed off and verified the insulin pens did not have a readable open date. On 02/17/22 at 10:10 AM, Administrative Nurse D stated staff should ensure insulin pens were dated when opened to maintain the effectiveness of the medication. The Medication Storage Policy, dated May 2019, directed staff to store medications per manufacturer guidelines to maintain the medication therapeutic…

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 12 residents. The sample included 12 residents. Based on interviews and record review the facility failed to provide change of condition notification to one Resident's (R83) representative when he transferred to the hospital. Findings included: - R83's electronic medical record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), atrial fibrillation (rapid, irregular heart beat), and acute kidney failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Five Day Minimum Data Set dated 06/12/20 documented a Brief Interview for Mental Status score of 2, which indicated severely impaired cognition. The baseline Care Plan dated 06/10/20 documented R83 had short and long- term memory deficits. He required extensive staff assistance for his Activities of Daily Living and uses a wheelchair for locomotion. He was at risk for falls due to multiple medications, gait problems, impaired balance, age, and dementia (progressive mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 12 residents. The sample included 12 residents. Based on observation, interviews, and record review the facility failed to update the care plan to reflect change in code status for Resident (R) 32. Findings included: - The Diagnoses tab of R32's electronic medical record (EMR) documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord ), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), and pressure ulcer of right buttock. The Annual Minimum Data Set (MDS) dated [DATE] revealed R32 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R32 required total dependence with two staff assistance for bed mobility, toileting, and transfers. R32 required total dependence with one staff for locomotion, dressing, eating, and personal hygiene. The Quarterly MDS dated 05/25/2020 revealed R32 had a BIMS score of…

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

The facility identified a census of 12 residents. The sample included 12 residents. Based on interviews and record review the facility failed to document a recapitulation of the facility stay upon discharge from the facility for Resident (R) 35 sampled for discharge. Findings included: - The Diagnoses tab of R35's electronic medical record (EMR) documented diagnoses of malignant neoplasm of the frontal and occipital lobes (brain cancer), hemiplegia (paralysis of one side of the body), and muscle weakness. R35's admission Minimum Data Set dated 12/10/19 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. He required limited to extensive staff assistance with his Activities of Daily Living (ADLs). The ADL Functional/Rehabilitation Potential Care Area Assessment dated 12/10/19 documented R35 required staff assistance for his ADLs due to his diagnoses. The Care Plan dated 12/12/19 documented R35's goal was to be discharged to home but, due to continuing decline in his condition he required a setting which was able to meet 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 12 residents. The sample included 12 residents. Based on record reviews, observations, and interviews the facility failed to ensure Resident (R)19 received treatment and care in accordance with professional standards of practice when the facility failed to follow a physician's order which directed staff to apply compression stocking (specially made socks which help prevent leg swelling and possible blood clots) to R19's lower extremities. Findings included: - The Diagnoses tab of R19's electronic medical record (EMR) documented diagnoses of chronic obstructive pulmonary failure (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, hemiplegia of his left side (paralysis of one side of the body), and acute/chronic renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 12 residents. The sample included 12 residents with one resident 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 observations, interviews, and record reviews, the facility failed to follow wound care orders for Resident (R) 32 as ordered by the wound care center provider for a stage four (wound that extends below the subcutaneous [beneath the skin] fat into deep tissues like muscles, tendons, and ligaments) pressure ulcer on the resident's right buttocks/ischium (part of the hip bone). Findings included: - The Diagnoses tab of R32's electronic medical record (EMR) documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), and pressure ulcer of…

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

The facility identified a census of 12 residents. The sample included 12 residents with three residents sampled for accidents. Based on observations, interviews, and record reviews the facility failed to ensure staff implemented interventions to prevent injury from falls when staff failed to provide a floor mat as indicated in R2's plan of care. This deficient practice placed R2 at risk for injury due to falls and/or accidents. Findings included: - R2's electronic medical record (EMR) documented diagnoses of muscle weakness, difficulty walking, cognitive communication deficit, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 09/18/19 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. She required extensive staff assistance with her Activities of Daily Living (ADLs). She was incontinent of bowel and bladder. She had no falls since…

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 12. The sample included 12 residents with one resident reviewed for feeding tube (tube for introducing high calorie fluids into the stomach). The facility failed to provide appropriate care and services to prevent complications of enteral feedings when staff failed to date and time the feeding tube administration tubing and feeding formula bag for Resident (R) 32. Findings included: - The Diagnoses tab of the electronic medical record (EMR) documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord ), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), adult gastrostomy status (surgical creation of an artificial opening into the stomach thru the abdominal wall), and dysphagia (difficulty swallowing). The Annual Minimum Data Set (MDS) dated [DATE] revealed R32 did not have a feeding tube at the time of the assessment. The 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 identified a census of 12 residents. The sample included 12 residents. Based on observations, interviews, and record reviews, the facility failed to assess Resident (R) 32's pain before, during, and after wound dressing change. Findings included: - The Diagnoses tab of R32's electronic medical record (EMR) documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord ), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), and pressure ulcer (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 ) of right buttock/ischium (part of the hip bone) stage four. The 'Annual Minimum Data Set' (MDS) assessment dated [DATE] revealed R32 complained of pain rarely during the assessment period and did receive PRN (as needed) pain medication. The Quarterly MDS assessment dated [DATE]…

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 12 residents. The sample included 12 residents. Five residents were sampled for unnecessary medication review. Based on observations, record reviews, and interviews the facility failed to ensure the Consultant Pharmacist (CP) identified and reported a blood pressure medication was given outside of the Primary Care Provider's (PCP) ordered parameters for Resident (R) 14. Findings included: - The Diagnoses tab of R14's electronic medical record (EMR) documented diagnoses of atrial fibrillation (rapid irregular heartbeat) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. She required extensive to total staff assistance with her Activities of Daily Living (ADLs). The Quarterly MDS dated 05/13/20 documented a BIMS score of seven, which indicated severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 12 residents. The sample included 12 residents. Five residents were sampled for unnecessary medication review. Based on observations, record reviews, and interviews the facility failed to hold antihypertensive (medication used to treat high blood pressure) medication for Resident (R) 14, when her blood pressures were outside standing order parameters. Findings included: - The Diagnoses tab of R14's electronic medical record (EMR) documented diagnoses of atrial fibrillation (rapid irregular heartbeat) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. She required extensive to total staff assistance with her Activities of Daily Living (ADLs). The Quarterly MDS dated 05/13/20 documented a BIMS score of seven, which indicated severely impaired cognition. She required…

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.