Holiday Resort Of Salina

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 45 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure one resident, Resident (R) 5 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication without an appropriate indication for use. The facility failed to ensure the physician provided the risk versus benefit for the continued use of antipsychotic medications. This placed R5 at risk of unnecessary medication administration and related complications.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification and State Ombudsman Agency notification of Resident (R) 32's discharge from the facility. This placed R32 at risk for being uninformed.Findings included:- R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following 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 an artery to the brain) affecting the left non-dominant side, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), nicotine dependence, cigarettes, lymphedema (tissue swelling caused by accumulation of protein rich fluid),…

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 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with individualized, resident-centered interventions for dementia (a progressive mental disorder characterized by failing memory and confusion) care, behaviors, and communication for one resident, Resident (R) 5. This placed the resident at risk for unmet care needs.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made or the boy cannot respond to the insulin).The Quarterly Minimum Data Set (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 had a census of 45 residents. The sample included 12 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to implement alternative communication methods for one resident, Resident (R) 5, who spoke Spanish. This placed the resident at risk for unmet needs, frustration, and agitation.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the boy cannot respond to the insulin).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. The MDS documented R5 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 45 residents. The sample included 12 residents, with 4 reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two residents, Resident (R) 6 and R8. This placed the residents at risk for complications related to poor hygiene.Findings included:- The Electronic Medical Record (EMR) for R6 recorded diagnoses of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), heart failure, dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition. R6 was independent for eating, oral hygiene, dressing, personal hygiene, mobility, and transfers. R6 required substantial staff assistance with bathing. R6's Care Plan,…

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 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision for Resident (R) 32, who smoked and had a staff-assisted descent to the ground while being assisted with a chair-to-chair transfer. This placed R32 at risk for injuries from smoking and falls.Included findings:- R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following 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 an artery to the brain) affecting the left non-dominant side, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), nicotine dependence, cigarettes, lymphedema (tissue swelling…

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 45 residents. The sample included 12 residents, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for one resident, Resident (R) 5, who had dementia and received psychotropic (alters mood or thought) medication. This placed R5 at risk for decreased quality of life.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 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 had a census of 45 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars (a system which measures blood glucose in the body) outside of ordered parameters for one resident, Resident (R) 20. This placed the residents at risk for adverse effects related to medication.Findings included:- The Electronic Medical Record (EMR) for R20 documented diagnoses of Diabetes Mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had moderately impaired cognition. R20 required substantial assistance from staff for upper body dressing, personal hygiene, 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 45 residents. The sample included 12 residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 5 and R2. This placed the residents at risk for inappropriate and/or unmet end-of-life care.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder 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 44 residents. The sample included eleven residents with eleven residents reviewed for residents right to dignity. Based on observation, record review, and interview, the facility failed to protect Resident (R) 1's dignity when R1 put on his call light because he had to have a bowel movement and a Certified Nurse's Aide (CNA) came into his room turned off his call light, stated she would be right back, and did not return to R1's room for two hours. R1 was incontinent of bowel in bed. This deficient practice placed the R1 at risk for impaired dignity and psychosocial impairment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and severe obesity. The Quarterly Minimum Data Set (MDS), dated 09/06/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which…

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

The facility had a census of 44 residents. The sample included eleven residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing and/or showers for three residents, Resident (R)1, R3, and R11. This deficient practice placed the residents at risk for impaired dignity, infection, and alteration in skin integrity. Findings included: - R1's Electronic Medical Record (EMR) documented that R1 had diagnoses of spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and severe obesity. The Quarterly Minimum Data Set (MDS), dated 09/06/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 had impairment on both sides of his lower extremities and was dependent on staff for toileting hygiene, dressing, and transfer 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 44 residents. The facility identified six residents with COVID-19 (highly contagious respiratory virus) in the facility. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection when reusable equipment was not disinfected between resident use and/or storage in common areas. The facility further failed to ensure Certified Nurse Aide (CNA) M informed the facility he had COVID-19 symptoms and tested positive for COVID-19. This placed the resident's at risk for infection. Findings included: - The facility's COVID-19 staff infection log documented CNA M tested positive for the virus on 11/29/23 but had symptoms that started on 11/23/23. The staffing sheet for the dates of 11/23/23, 11/24/23, and 12/01/23 documented CNA M worked the evening shift. The COVID-19 resident infection log documented 26 residents since 11/17/23 were ill with COVID-19. On 12/07/23 at 02:00 PM, observation revealed Administrative Nurse D…

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 41 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure the kitchen walk-in freezer was in safe operating condition, when the freezer door continued to build up with ice and fail to completely shut. This placed the 41 residents who resided in the facility and received their meals from the facility kitchen at risk for foodborne illness. Findings included: - On 11/01/23 at 08:30AM, observation in the kitchen revealed the walk-in freezer door had ice buildup on the frame of the door and would not stay closed. On 11/06/23 at 12:40 PM, Maintenance Staff (MS) U stated he had been employed at the facility for six years and he was aware of the problems with the walk-in freezer door building up with ice and not shutting. MS U verified the issue had been going on for quite a while. MS U stated he had talked to six or seven refrigeration vendors and turned in the price to replace the freezer, but the problem had not yet received a permanent fix. On 11/06/23 at 02:46 PM, Dietary Staff (DS) BB…

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 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise, update, and individualize the care plans for Resident (R) 9 who received oxygen and respiratory treatment, R13 with a urinary catheter (tube inserted in the bladder to drain urine), R24 who received insulin (a hormone to regulate blood sugar) and a diagnosis of diabetes mellitus when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), R25 who was on a fluid restriction, and R19 and R22 who were at risk for falls. This deficient practice placed the residents at risk for inadequate and/or inappropriate care related to uncommunicated care needs. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data…

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 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards with staff left one of two treatment carts unsupervised and unlocked in the hall by the living room area. This placed the six cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. Finding included: - On 11/02/23 at 08:18 AM, observation revealed a treatment cart unlocked and unsupervised. The cart contained the following items: The first drawer had a pair of scissors, numerous rolls of tape, one (1.5 fluid ounce) bottle antiseptic cleanser and a 22-gauge needle. The second drawer had four boxes of medicated arthritis pain gel, three boxes of albuterol sulfate (0.83 %) inhalation solution (breathing treatment), two tubes of medicated triamcinolone acetonide cream (medication used to treat a variety of skin conditions), two boxes of Spiriva (breathing treatment) one box of ipratropium bromide inhaler (medication used to open airways), one…

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 41 residents. The sample included 12 residents with one reviewed for dialysis (procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to adhere to Resident (R) 25's fluid restriction, placing R25 at risk for fluid overload, and dialysis complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnosis of stage 4 chronic kidney disease (advanced kidney disease), and dependence on dialysis. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R25 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further documented R25 required minimal assistance with activities of daily living (ADLs). R25 was able to feed herself. She received dialysis three times a week. The Dehydration/Hydration Care Area Assessment Summary (CAA), dated 09/06/23, stated R25 received dialysis three times a week and was on a fluid restriction…

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 41 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the appropriate treatment and services to attain Resident (R) 23's highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being when staff failed to provide R23 with mental and behavioral health services. This placed the resident at risk for decreased quality of care and life. Findings included: - R23's Electronic Medical Record (EMR) documented R23 had diagnoses of trigeminal neuralgia (chronic painful disease which affects the trigeminal nerves present in the face)and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R23's Quarterly Minimum Data Set (MDS), dated [DATE], documented R23 had short- and long-term memory problems and severely impaired cognition. The MDS documented the resident was dependent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review and interview, the facility failed to provide adequate medical social services to meet Resident (R) 23's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life. Findings included: - R23's Electronic Medical Record (EMR) documented R23 had diagnoses trigeminal neuralgia (chronic painful disease which affects the trigeminal nerves present in the face) and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R23's Quarterly Minimum Data Set (MDS), dated [DATE], documented R23 had short- and long-term memory problems and severely impaired cognition. The MDS documented the resident was dependent on staff for most activities of daily living (ADLs) and had behaviors of inattention, altered level of consciousness which fluctuated, and disorganized thinking which were…

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 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to deliver mail in a timely manner which included Saturday. This placed the residents at risk to not receive their communications in a timely manner. Findings included: -On 04/11/22 at 08:52 AM, observation revealed a box labeled Saturday Mail in the entry commons space of the facility containing several envelopes and a paper flyer. On 04/11/22 at 08:52 AM, Administrative Staff A reported the mail was delivered on 04/09/22 and had not been distributed to the residents. Administrative Staff A stated it was the nursing staff's responsibility to deliver the Saturday mail. The facility's undated admission Agreement Resident Rights policy documented the facility must protect and facilitate that resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to stationery, postage, writing implements, and the ability to send mail. The facility failed to ensure the residents…

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 40 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for six residents, Resident (R)17, R15, R26, R19, R30 and R33. This placed the residents at risk for inadequate nutrition. Findings included: - On 04/11/22 at 10:30 AM, observation revealed Dietary Staff (DS) BB prepared six pureed diets. DS BB placed approximately four slices, approximately three ounces of baked meat loaf in a food processor/blender. DS BB blended the meatloaf, added an unmeasured amount of beef broth, emptied the meatloaf into a stainless-steel food storage container, then stored the container in the oven. DS BB placed approximately two- and one-half cups of peas in a blender with some juice, blended the peas, emptied the peas into a stainless-steel food storage container, and placed the container in the oven. On 04/11/22 at 11:00 AM, DS BB stated she was unaware she needed to follow a pureed recipe and stated she would blend the food and add the unmeasured amount of liquid to make…

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 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide assistance at mealtime for dependent Resident (R) 139, who had a history of a 7.6 percent weight loss in one month. This placed the resident at risk for continued weight loss. Findings included: -R139's Physician Order Sheet (POS), dated 02/28/22, documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body), facial weakness following nontraumatic intracerebral hemorrhage (ruptured blood vessel causing bleeding inside the brain), aftercare following surgery for malignant neoplasm (cancer tumor) of frontal lobe (brain), mild protein-calorie malnutrition, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The admission Minimum Data Set (MDS), dated [DATE], documented R139 had intact cognition, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 40 residents. The sample included 16 residents with two 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). The facility failed to prevent the development of a Stage 2 pressure ulcer (partial thickness loss of skin, presenting as a shallow open ulcer with a red pink wound bed) for Resident (R) 20 and R17. This placed the residents at risk for further skin breakdown, pain, and skin infection. Findings included: - R20's Physician Order Sheet, dated 02/01/22, recorded a diagnosis of morbid obesity (a person is at least 100 pounds overweight), venous insufficiency peripheral (failure of the veins to adequately circulate blood, especially in the lower extremities), kidney disease Stage 3 (the kidney's have mild to moderate damage, and they are less able to filter waste and fluid out of the blood), and depression (abnormal emotional state…

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 has a census of 40 residents. The sample included 12 residents with two reviewed for urinary catheter. Based on observation, record review and interview, the facility failed to ensure Resident (R) 25's urinary catheter system (tube placed in the bladder to drain urine into a collection bag) had not touched the floor. This placed R25 at risk for urinary tract infections (UTI - infection in the bladder or kidneys). Findings included: - R25's Physician Order Sheet (POS), dated 03/01/22, recorded diagnoses of hemiplegia and hemiparesis (paralysis and muscle weakness of one side of the body) following a cerebral infarction (stoke), malignant neoplasm (cancer tumor) of prostate, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had moderately…

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 40 residents. The sample included 12 residents with three reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide routine weight monitoring for Resident (R) 139, who had a history of a 7.6 percent weight loss in one month. This placed the resident at risk for delayed identification and interventions to prevent further loss weight loss. Findings included: - R139's Physician Order Sheet (POS), dated 02/28/22, documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body), facial weakness following nontraumatic intracerebral hemorrhage (ruptured blood vessel causing bleeding inside the brain), aftercare following surgery for malignant neoplasm (cancer tumor) of frontal lobe (brain), mild protein-calorie malnutrition, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) . The admission…

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 40 residents. The sample included 12 residents. Based on observation and interview the facility failed to ensure staff possessed adequate competencies to store, prepare, and secure medication and medical information during medication pass. This placed residents at risk of compromised medications and exposure of medical information. Findings included: -On 04/13/22 at 07:30 AM, observation revealed an unattended medication cart on the 300 Hall with a clear plastic medication cup with several pills of a variety of color and shapes on the top of the cart. The electronic medication administration record (eMAR) was visible on a computer screen which contained information related to a resident's medical record. Licensed Nurse (LN) G emerged from Resident (R) 24's room, approached the medication cart and minimized the computer screen. LN G took the medication cup containing the various colors and shapes into R24's room, leaving the medication cart unlocked and out of visual range of the nurse. LN G then proceeded to prepare R139's medication for administration.…

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 40 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 the Consultant Pharmacist identified and reported to the Director of Nursing, medical director, and physician, the inappropriate diagnosis for the use of an antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five residents, Resident (R) 137. This placed the resident at risk for inappropriate use of an antipsychotic medication. Findings included: - R137's Physician Order Sheet (POS) documented diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The admission Minimum Data Set (MDS), 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 had a census of 40 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 obtain an appropriate diagnosis for Resident (R) 137's use of an antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) medication. This placed the resident at risk of receiving unnecessary psychotropic (medications that affect a person's mental state) medication. Findings included: - R137's Physician Order Sheet (POS) documented diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], documented R137 had severe cognitive impairment, inattention which fluctuated, 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 40 residents. The sample included 12 residents with one reviewed for dental care. Based on observation, record review and interview, the facility failed to provide timely dental care for one sampled resident, Resident R (20). This placed R20 at risk for pain, dietary concerns, and dental issues. Findings included: - R20's Physician Order Sheet, dated 02/01/22, recorded diagnoses of morbid obesity (a person is at least 100 pounds overweight), venous insufficiency peripheral (failure of the veins to adequately circulate blood, especially in the lower extremities), kidney disease Stage 3 (the kidney's have mild to moderate damage, and they are less able to filter waste and fluid out of the blood), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R20's admission Minimum Data Set (MDS), dated [DATE], recorded she had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. 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 40 residents. Based on observation, record review, and interview the facility failed to serve food under sanitary conditions for Resident (R) 18 and R9 during the meal service. This placed the residents at risk for contaminated food. Findings included: - On 04/11/22 at 12:20 PM, during the meal service, observation revealed Certified Nurse Aide (CNA) N in the main dining room took a spoon and a knife and cut up R18's hamburger into quarters. The resident did not pick up the hamburger. CNA N picked up the quarter pieces of hamburger with her bare hand and put it up to R18's mouth to assist her to eat the meal. CNA N did this a few times during the meal service. On 04/11/22 at 12:30 PM, during the meal service, observation revealed CNA N went from the table she was assisting R18 to the hydration bar and got two cups and delivered the drinks to R9's table. CNA N then removed the paper from the two straws with her bare hands, touched the bendable straw tip the resident would drink from, and placed the straws into the two cups in front of the resident. R9…

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.