Smoky Hill Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide activities of daily living support for Resident (R) 44 and R48, who required assistance from staff. This placed the residents at risk for ongoing unmet needs and care. Findings included: - R44's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin(a hormone that lowers the level of glucose in the blood)), morbid obesity (excessive body fat), major depressive disorder (major mood disorder that causes persistent feelings of sadness), delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, restless leg syndrome, chronic pain, lymphedema (swelling caused by accumulation of lymph), and chronic respiratory failure 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 65 residents. The sample included 13 residents, with four residents reviewed for urinary catheter (tube inserted into the bladder to drain urine into a collection bag) or urinary tract infection (UTI - an infection in any part of the urinary system). Based on observation, interview, and record review, the facility failed to provide urinary catheter care in a manner to prevent urinary tract infections for Resident (R) 12. This deficient practice placed R12 at risk for infections and catheter-related complications. Findings included: - R12's Electronic Medical Record documented diagnoses of cerebral infarction (stroke), 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), and infection due to an indwelling urinary catheter. R12's Annual Minimum Data Set (MDS), dated [DATE], documented R12 had severely impaired cognition. The MDS documented R12 required moderate assistance for…

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

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to monitor Resident (R) 48's physician order for fluid restriction. This placed R48 at risk of complications related to hydration status due to the resident's cardiac status. Findings included: - The Electronic Medical Record (EMR) for R48 documented diagnoses of hypertension (HTN-elevated blood pressure), 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), chronic kidney disease, angina (chest pain) pectoris, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and 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 65 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to obtain an appropriate indication or the required physician documentation for the continued use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication for R42. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and potential adverse effects. Findings included: - R42's Electronic Medical Record documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and generalized anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear). R42's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 13 residents, with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 18, who admitted to hospice on 02/25/25, which included a plan of care and a description of the services provided, such as contact information, visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving needed care. Findings included: - R18's Electronic Health Record (EHR) revealed diagnoses of sarcopenia (a condition characterized by the progressive decline of skeletal muscle mass, strength, and function) and transient ischemic attack (TIA - temporary episode of inadequate blood supply to the brain). R18's Significant Change Minimum Data Set (MDS), dated [DATE], documented R18 had a Brief Interview of Mental Status (BIMS) of 12, which indicated moderately impaired cognition. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to ensure R43's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) tubing and uncovered bag off the floor. Findings included: - R43's Electronic Medical Record (EMR) documented that R43 had diagnoses of obstructive and reflux uropathy (a condition where the normal flow of urine through the urinary tract is blocked, while reflux uropathy (vesicoureteral reflux or VUR) is when urine flows backward from the bladder to the ureters (small tubular structure that drains urine from the bladder) and kidneys (a pair of organs in the abdomen which remove waste and extra water from the blood (as urine) and help keep chemicals (such as sodium, potassium, and calcium) balanced in 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 65 residents. The sample included 13 residents. Based on the interview and record review, the facility failed to offer pneumococcal (type of bacterial infection) PCV20 immunizations for Residents (R)3, R18, and R39, per the guidance from the Centers for Disease Control and Prevention (CDC). This placed the resident at risk for pneumococcal infection. Findings included: - R3's Electronic Medical Record (EMR) documented R3 received one Prevnar 13 dose on 04/30/15. The facility lacked documentation of whether R3 was offered or refused any further pneumococcal vaccinations. R18's EMR documented R18 received one Prevnar 13 dose on 03/12/15. The facility lacked documentation of whether R18 was offered or refused any further pneumococcal vaccinations. R39's EMR lacked pneumococcal information, whether R29 was offered, or refused any pneumococcal vaccinations. On 04/23/25 at 02:06 PM, Administrative Nurse E stated she was not aware of the CDC guidance related to the PCV 20 immunization. The facility's Pneumococcal Vaccine policy, dated 08/2016, documents all…

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 77 residents with three residents reviewed for neglect. Based on record review and interview, the facility failed to develop and implement written policies and procedures that included what constitutes and how to recognize abuse, neglect, and exploitation of residents, and misappropriation of resident property. This failure placed all cognitively imapired residents who lived at the facility at risk for ongoing abuse or neglect. (Refer to F600) Findings included: - A review of the facility policy Abuse Prevention Program, revised in December 2016 revealed the policy stated staff would identify and assess all possible incidents of abuse but lacked provision on what constitutes abuse, neglect, exploitation, and misappropriation of resident property. The policy further lacked direction on how to recognize signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. On 02/21/24 at 10:53 AM, Administrative Staff A stated the facility abuse policy provided at the time of the survey was 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 identified a census of 76 residents with three residents reviewed for infection control. Based on record review, observation, and interview, the facility failed to provide Resident (R) 2 a safe, clean, comfortable, and homelike environment when staff stripped R2's urine-soaked bedding and left them on the end of his bed creating an unpleasant smell in R2's room. This deficient practice placed R2 at risk for an unclean and uncomfortable environment. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of 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), aphasia (condition with disordered or absent language function), hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body). The Quarterly Minimum Data Set (MDS), dated 11/02/23, documented R2 was rarely/never understood and R2's cognition for making daily decisions was severely impaired. The Cognitive Loss/Dementia…

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 76 residents with three residents reviewed for infection control. Based on record review, observation, and interview, the facility failed to utilize accepted infection control practices when Certified Nurse's Aide, (CNA) M performed peri care on Resident (R) 2 without using gloves. This deficient practice placed R2 at risk for infections and an unclean environment. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of 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), aphasia (condition with disordered or absent language function), hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body). The Quarterly Minimum Data Set (MDS), dated 11/02/23, documented R2 was rarely/never understood and R2's cognition for making daily decisions was severely impaired. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/04/23, documented R2 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 78 residents. The sample included six residents. Based on observation, record review, and interview, the facility failed to provide a baseline care plan within 48 hours of admission for Resident (R) 1, which placed the resident at risk for unmet care needs. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of acute on chronic heart failure, acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute kidney failure, mitral valve (located between upper and lower heart chamber) insufficiency, acute ischemic heart (decreased supply of oxygenated blood to a body part) disease, and chronic pain syndrome. R1's Comprehensive Admission/Medicare 5-day Minimum Data Set (MDS) was not yet completed due to recent admission. R1's clinical record lacked a baseline 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.

The facility had a census of 78 residents. The sample included six residents. Based on observation, record review, and interview, the facility failed to provide interventions to prevent skin breakdown for Resident (R) 6 who had shearing (the separation of skin layers caused by friction or trauma). This placed R6 at increased risk for 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) and delayed healing. Findings included: - R6's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic kidney disease, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cardiac arrhythmia (heart irregularity), and diaphragmatic hernia (protrusion of an organ through an abnormal opening in the muscle wall of the cavity that surrounds it) with obstruction. R6's Comprehensive Admission/Medicare 5-…

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 78 residents. The sample included six residents. Based on observation, interview, and record review, the facility failed to provide a dysphagia (swallowing difficulty) diet for Resident (R) 6 as ordered by the physician. This placed the resident at risk of choking and decreased nourishment. Findings included: - R6's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic kidney disease, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cardiac arrhythmia (heart irregularity), and diaphragmatic hernia (protrusion of an organ through an abnormal opening in the muscle wall of the cavity that surrounds it) with obstruction. R6's Comprehensive Admission/Medicare 5- day Minimum Data Set (MDS) was not yet completed due to recent admission. R6's Baseline Care Plan, dated 12/21/23, documented R6 required a regular dysphagia diet (special diet consisting of foods which are easier to…

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

The facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient weekend staffing. This placed the facility residents at risk for a decline and inadequate resident cares being completed. Findings included: - A review of the Facility Assessment dated 05/07/23 indicated the facility should have a three to five Licensed Nurses (LN), ten -seventeen Certified Nurse's Aides (CNA). The Payroll-Based Journal (PBJ -Staffing Data Report) indicated the facility triggered for excessively low weekend staffing (submitted weekend staffing data was excessively low) for Fiscal Year (FY) Quarter three 2022 through FY Quarter two (April 1, 2022- March 31, 2023). A review of the facility's Posted Staffing for Tuesday (06/07/22) indicated day shift (06:00AM- 02:00PM) had three Registered Nurse's (RN), three Licensed Vocational Nurse LVN, one Certified Medication Aide (CMA), and eight CNA's. The census was 58 residents. A review of the facility's Posted Staffing for Saturday (06/11/22)…

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.

The facility identified a census of 69 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed all the residents who received food from the facility kitchen at risk related to food borne illnesses and food safety concerns. Findings included: - On 08/14/23 at 07:27 AM an observation in the main kitchen area revealed three opened bags of wheat bread on a plastic storage shelf. One bag was open to air and undated. On 08/14/23 at 07:28 AM an observation in the main kitchen area revealed two opened bags of hotdog buns on a plastic storage shelf. The bags were undated. On 08/14/23 at 07:29 AM an observation in the kitchen's walk-in refrigerator revealed one cut in half onion in a resealable bag. The bag was undated. On 08/14/23 at 07:31 AM an observation in the kitchen's walk-in refrigerator revealed ham in a pan covered with foil. The foil had a large tear on one side which left the ham exposed to air. On 08/14/23 at 07:32 AM an observation in 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 identified a census of 69 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and boredom. Findings Included: - A review of the facility's Activity Calendar for August, June, and July of 2023 indicated on Saturdays the residents would socialize, read, and get fresh air outside the facility (weather permitted). The calendars indicated a movie would be played on some Saturdays. The calendar revealed either a church service or television service would be provided to the residents. The calendar indicated a Sunday Newspaper was provided for the residents. On 08/16/23 at 02:01 PM, Resident Council members reported the Activity Coordinator (AC) Z worked Monday through Friday. The council reported most weekends do not have staff led activities or scheduled groups for the residents to attend. The council reported Saturdays were more individually ran for each resident to…

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

The facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to storage of respiratory equipment, hand hygiene during wound care, foam wheelchair cushion cleanliness, and monitoring of washing machine water temperature. These deficient practices had the risk to spread illness and infections to all residents. Findings included: - On 08/14/23 at 07:04 AM Resident (R) 34's undated continuous positive airway pressure (CPAP- a ventilation device that is used to treat sleep apnea, that blows a gentle stream of air into the nose to keep airway open during sleep) mask was stored in the top drawer of the bedside table without a bag. On 08/14/23 at 07:14 AM R47's foam wheelchair cushion was uncovered in the wheelchair. R47 stated the cover had been missing for over a month. On 08/16/23 at 01:22 PM R17 laid on the bed on a low air loss mattress. Licensed Nurse (LN) G and Administrative Nurse E explained the procedure to R17.…

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 69 residents. The sample included 18 residents with two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to provide care in a respectful, dignified manner for Resident (R) 28 and R48. This placed the residents at risk for impaired dignity and quality of life. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), weakness 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 the sacral (area at base of spine) regions, stage 2 ( partial thickness). The Quarterly MDS dated 07/17/23 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R28 required extensive assistance of two staff members for most activities of daily living…

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

The facilty idenitfied a census of 69. The sample inlcuded 18 residents. based on observation, interview, and record review, the facility failed to ensure Resident (R)48 received a pressure reducing device for her wheelchair, in order to reduce the risk for pressure injury development. This placed R48 at increased risk for avoidable pressure injuries. Findings included: - The electronic medical record (EMR) for R48 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), history of falling, unsteadiness on feet, and weakness. R48's Quarterly Minimum Data Set (MDS) dated 07/14/23 noted a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS recorded R48 required extensive assistance of one staff member for bed mobility, transfers, locomotion on and off unit, dressing, toileting, and personal hygiene. The MDS further recorded R48 had a pressure reducing device for her bed and was at risk for developing pressure ulcers. The Cognitive Impairment/Dementia Care Area Assessment (CAA)…

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 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide a sanitary and clean homelike environment for Resident (R) 58, who had food crumbs left in the wheelchair. This deficient practice placed R58 at risk of pests and impaired psychosocial wellbeing. Findings included: - R58's Electronic Medical Record (EMR) do under the Diagnosis tab documented diagnoses of 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), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) and falls. R58's Quarterly Minimum Data set (MDS) dated [DATE] the cognition interview was not conducted with the resident as the resident was rarely/never understood. The MDS documented a staff interview which revealed the resident had short- and long-term memory problems.…

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 69 residents. The sample included 18 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R) 28. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. R28's EMR recorded a Discharge Assessment-Return Anticipated Minimum Data Set (MDS) which recorded R28 discharged to the acute hospital on [DATE]. R28's Entry Tracking Record MDS documented R28 returned to the facility on [DATE]. Another Discharge Assessment-Return Anticipated dated 07/04/23 recorded R28 discharged to the acute hospital and the Entry Tracker…

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 69 residents. The sample included 18 residents with one resident reviewed for hospitalization. Based on observation, interview and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)28 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's two transfers to the hospital. This placed the resident at risk for impaired rights. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. R28's EMR recorded a Discharge Assessment-Return Anticipated Minimum Data Set (MDS) which recorded R28 discharged to the acute hospital on [DATE]. R28's Entry Tracking Record MDS documented R28 returned to the facility on [DATE]. Another Discharge Assessment-Return Anticipated dated…

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

The facility identified a census of 69 residents. The sample included 18 residents with five residents reviewed for activities of daily living (ADLs) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for Resident (R) 55 who required extensive assistance from staff to complete the care. This deficient practice placed R55 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R55's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (a terminal disease because of irreversible damage to vital tissues or organs) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R55 required extensive assistance of two staff members…

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 69 residents. The sample included 18 residents with five residents reviewed for prevention and treatment of 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 staff implemented appropriate infection control practices during wound care for Resident (R) 17, who had a history of a wound infection. The facility also failed to ensure pressure reducing measures were in place for R46. This deficient practice placed these residents at risk of development of pressure ulcers, of wound worsening and complications related to infections. Findings included: - R17's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) 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 had a census of 69 residents. The sample included 18 residents with one reviewed for incontinence cares. Based on observation, record review and interview the facility failed to implement an individualized toileting plan for Resident (R)123. This deficient practice placed R123 at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R123's Electronic Medical Records (EMR) included diagnoses of cerebrovascular accident (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), chronic kidney disease, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, psychosis (any major mental disorder characterized by a gross impairment in reality testing), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and history 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 69 residents. The sample included 18 residents with two residents reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review, the facility failed to assess and document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day, and failed to obtain communication from the dialysis center and assess post dialysis for Resident (R) 55. This deficient practice placed the resident at risk for complications related to dialysis. Findings included: - R55's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (a terminal disease because of irreversible damage to vital tissues or organs) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body…

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 69 residents. The sample included 18 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)58, who had an ordered one-quarter side rail on the right side of his bed but actually had a larger rail, attached to the left side. This placed the resident at risk for injury related to incorrect or unsafe use of side rails. Findings included: - R58's Electronic Medical Record (EMR) do under the Diagnosis tab documented diagnoses of 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), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) and falls. R58's Quarterly Minimum Data set (MDS) dated [DATE] the cognition interview was not conducted with the resident as the resident was rarely/never…

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 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 19's therapeutic diet as ordered by her physician. This deficient practice placed R19 at risk for choking and malnutrition. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of cerebral infection (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), dementia (progressive mental disorder characterized by failing memory, confusion), and dysphagia (swallowing difficulty). R19's Quarterly Minimum Data Set (MDS) dated 06/29/23 noted a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS noted that she required supervision and set-up only for eating. The MDS noted that she had weight loss within the last six months but was not on a physician prescribed weight loss plan. R19's Care Plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 69 residents. The sample included 18 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was in place to communicate necessary information regarding Resident (R) 17's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial care for R17. Findings included: - R17's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and pressure ulcer of unspecified buttock, unspecified stage. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 55 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for R7, placing the resident at risk for undignified care and services. Findings included: - The Electronic Medical Record (EMR) documented R7 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), type 2 diabetes mellitus (when the body cannot use sugar, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had 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 had a census of 55 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to complete a medication self-administration assessment for Resident (R) 20. This placed the resident at risk to not receive his medications or receive the wrong dose of the medications. Findings included: - R20's Electronic Medical Record (EMR) documented diagnoses of type 2 diabetes mellitus (when the body cannot use sugar, not enough insulin made or the body cannot respond to the insulin), depressive disorders (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), heart failure, fluid overload, and acute (disease characterized by a relatively sudden onset of symptoms that are usually severe) kidney failure (one or both kidneys can no longer function well on their own). R20's Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview of Mental Status score 15, which indicated intact cognition.…

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 55 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to accommodate the needs of Resident (R) 7, when staff did not provide a chair pad in a recliner the resident wanted to sit in which prevented R7 from sitting in her preferred chair. This placed the resident at risk for discomfort and impaired dignity Findings included: - The Electronic Medical Record (EMR) documented R7 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), type 2 diabetes mellitus (when the body cannot use sugar, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness,…

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 55 residents. The sample included 16 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide one of three sampled residents, Resident (R) 52 (or their representative) the completed Notice of Medicare Non-Coverage Form (NOMNC) 10123 Centers for Medicare and Medicare Services (CMS). This placed the resident at risk to make uninformed decisions about their skilled services. Findings included: - Medicare Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy. The form included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. The facility lacked documentation staff provided R52, or her representative, form 10123 which included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. The resident's skilled nursing services ended on 10/18/21. On 03/24/22 at 01:00 PM, Social Service Staff X verified the facility had not provided the resident and/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 had a census of 55 residents. The sample included 16 residents, with four reviewed for behaviors. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 11, who had multiple behaviors. This placed the resident at risk for inappropriate interventions to prevent or lessen behaviors. Findings included: - The Electronic Medical Record (EMR) documented R11 had diagnoses of senile degeneration of the brain (the mental deterioration that is associated with or the characteristics of old age), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, locomotion off the unit, and required extensive assistance of one staff for toileting and personal hygiene. The MDS further documented R11 had inattention, disorganized…

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 55 residents. The sample included 16 residents, with one reviewed for skin conditions. Based on observation, record review, and interview, the facility failed to update Resident (R) 10's care plan with an appropriate intervention to protect his toes, after he received an injury to his left big toe. This placed R10 at risk for further injuries to his toes. Findings included: - R10's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) following cerebral infarction (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 left non dominant side, and type 2 diabetes mellitus (when the body cannot use sugar, not enough insulin made or the body cannot respond to the insulin). R10's Annual Minimum Data Assessment MDS, dated [DATE], documented R10 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 55 residents. The sample included 16 residents with seven residents reviewed for activities of daily living (ADL's). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for three of the seven reviewed for ADLs. Resident (R) 38, R252 and R23. This placed the residents at risk for poor personal hygiene. Findings included: - The Electronic Medical Record (EMR) documented R38's diagnosis of below the knee amputation of both lower extremities (loss of lower legs), cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood), and schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves). R38's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition, required extensive assistance from two staff for transfers, personal hygiene and bathing did not occur. The ADL 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 55 residents. The sample included 16 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions for accidents for two sampled residents. R102 who had three falls from a recliner and R10 who sustained an injury on his toe. This placed the residents at risk for further injury. Findings included: - The Electronic Medical Record (EMR) for R102 documented diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness, and psychotic symptoms (any major mental disorder characterized by a gross impairment in reality testing). The admission Minimum Data Set (MDS), dated [DATE], documented R102 required extensive…

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 55 residents. The sample included 16 residents, with one resident reviewed for pain. Based on observation, record review, and interview. The facility failed to assess and administer pain medication in a timely manner to one sampled resident, Resident (R) 7, who had pain. This placed R7 at risk for further pain and discomfort. Findings included: - The Electronic Medical Record (EMR) documented R7 had diagnoses of osteoarthritis degenerative changes to one or many joints characterized by swelling and pain, dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), type 2 diabetes mellitus (when the body cannot use sugar, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Quarterly Minimum…

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 55 residents. The sample included 16, with two reviewed for dementia care. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services for one sampled resident (R) 11, who had dementia related behaviors. This placed the resident at risk for injury and unmet needs. Findings included: - The Electronic Medical Record (EMR) documented R11 had diagnoses of senile degeneration of the brain (the mental deterioration that is associated with or the characteristics of old age), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, locomotion off the unit, required extensive assistance of one staff for toileting, and personal hygiene. The MDS documented the resident had inattention, disorganized…

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 55 residents. The sample included 16 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 (46). This placed R46 at risk for weight loss and dental issues. Findings included: - R46's Electronic Medical Record (EMR) recorded diagnosis of type 2 diabetes mellitus (when the body cannot use sugar, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (major mood disorder), and heart failure. R46's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R46 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment revealed the resident required extensive staff assistance for personal hygiene, dressing and had no oral or dental issues. The Care Area Assessment (CAA), dated 08/05/21, for activities of daily living (ADLs) failed to identify or document any sign/symptoms of dental…

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 55 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for one resident, Resident (R) 27. This placed the resident at risk for inadequate nutrition. Findings included: - On 03/22/22 at 11:30 AM, observation revealed Dietary Staff (DS) BB prepared a pureed diet. DS BB placed two ounces of cooked turkey breast into a blender with 1/4 cup of hot water and blended, then emptied the turkey into a small bowl. DS BB placed two ounces of cooked brussel sprouts with four tablespoons of water into a blender, blended, and then emptied into a small bowl. DS BB placed a dinner roll and four tablespoons of water into a blender, blended, and then emptied into a small bowl. On 03/22/22 at 11:55 AM, DS BB stated he was unaware he needed to follow a pureed recipe and did not know of adding anything but water to food when blending for a pureed diet. On 03/28/22 at 10:00 AM, Administrative Staff A verified dietary staff should use a pureed recipe when preparing a pureed diet.…

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.