Shawnee Gardens Healthcare & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified at a census of 115 residents. The sample included 26 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R)37's call light was within his reach. This deficient practice left R37 vulnerable for unmet care needs due to the inability to call for staff assistance. Findings included: - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), bipolar disorder (a major…

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

The facility reported a census of 115 residents. The sample included 26 with 26 residents reviewed for care plan revisions. Based on observations, interviews, and record review, the facility failed to revise Resident (R)106's Care Plan to reflect his current toileting needs after discontinuation of his Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). This deficient practice placed R106 at risk for impaired care due to uncommunicated care needs. Findings Included: - R106's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of intracranial hemorrhage (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by rupture of an artery to the brain), aphasia (condition with disordered or absent language function), chronic kidney disease, and agitation. R106's Quarterly Minimum Data Set (MDS) completed 08/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS revealed no upper or lower extremity impairments. The MDS noted he…

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

The facility reported a census of 115 residents. The sample included 26 residents with eight reviewed for activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 99 received supportive care and services to promote and maintain her quality of life when the facility did not implement tools and/or strategies to allow R99 to communicate her wants, needs, or feelings. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - R99's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R99's Quarterly Minimum Data Set (MDS) completed 06/17/24 revealed…

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 115 residents. The sample included 26 residents with eight residents sampled for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance for Resident (R) 92 who was dependent on staff for ADLs. The facility also failed to ensure staff provided assistance for toileting and eating for R68 and R37. This placed these residents at risk for impaired care and decreased quality of life. Findings included: - R92's Electronic Medical Record (EMR) documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), dementia (a progressive mental disorder characterized by failing memory and confusion), and encephalopathy (a broad term for any brain disease that alters brain function or structure). R92's admission Minimum Data Set (MDS) dated 10/16/23 documented a Brief Interview for Mental Status (BIMS) score of 10…

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 115 residents. The sample included 26 residents with three sample residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's pressure-reducing interventions were implemented correctly when their low air-loss mattress pump was set at an inappropriate weight for the resident. This deficient practice placed R2 at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), heart failure (a condition with low heart output and the body becomes congested with fluid), and pressure ulcer of the sacral (large triangular bone/area between the two hip bones) region. R2's Annual Minimum Data Set (MDS) dated 03/09/24 documented a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 115 residents. The sample included 26 residents with five reviewed for accidents. Based on record review, interviews, and observations, the facility failed to implement the fall intervention of anti-rollback (device to prevent the wheelchair from rolling backward) devices per R41's care plan. The facility additionally failed to ensure a safe environment free from accident hazards when R36's bed was left in a high position. This placed the residents at risk for preventable accidents and injuries. Findings Included: - R41's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of dysphagia (difficulty swallowing), aphasia (difficulty speaking), hemiplegia (paralysis of one side of the body), and epilepsy (brain disorder characterized by repeated seizures). R41's Annual Minimum Data Set (MDS) completed 07/23/24 revealed a Brief Interview for Mental Status (BIMS) score of two indicating severe cognitive impairment. The MDS indicated he 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 identified a census of 115 residents. The sample included 26 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently communicate Resident (R) 37's medical condition with the dialysis center. This deficient practice placed R37 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), congestive heart failure (CHF-a condition with low heart output and the body becomes congested…

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 115 residents. The sample included 26 residents with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R)99 to promote the resident's highest practicable level of well-being. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - R99's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R99's Quarterly Minimum Data Set (MDS) completed 06/17/24 revealed a Brief Interview for Mental Status…

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

The facility identified a census of 115 residents. The sample included 26 residents with two medication rooms and four medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This placed the residents at risk for misappropriation and/or diversion of controlled substances. Findings included: - On 09/18/24 at 07:34 AM a review of the July, August, and September 2024 Narcotic Hand Off Count Sheet on the 100 halls revealed a missing signature either for the on-coming nurse or the off-going nurse for the morning shift on 07/27, 07/28, 08/03, 08/10, 09/03, 09/7, and 09/18. On 09/18/24 at 07:34 AM, a review of the July, August, and September 2024 Narcotic Hand Off Count Sheet on the 100 halls revealed a missing signature either for the on-coming nurse or the off-going nurse for the evening shift on 07/6, 7/27, 8/3, 8/5, 8/6, 8/23, 8/30, 9/2, 9/9, 9/13, and 9/16. On 09/18/24 at 07:42 AM Certified Medication Aide (CMA)R stated the narcotics were always to be counted between…

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 115 residents. The sample included 26 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported a missing dosage and location of the application for Resident (R) 92's physician-ordered diclofenac (a topical medication used to treat pain and swelling). The facility further failed to ensure the CP recommendations for R35 were submitted to the physician for review. This placed the residents at risk for unnecessary medication side effects. Findings included: - R92's Electronic Medical Record (EMR) documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), dementia (a progressive mental disorder characterized by failing memory and confusion), and encephalopathy (a broad term for any brain disease that alters brain function 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.

The facility identified a census of 115 residents. The sample included 26 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 92's physician ordered diclofenac (a topical medication used to treat pain and swelling) had an indicated dosage or an indicated location to apply the medication. This placed R92 at risk of unnecessary medication administration and possible adverse side effects. Findings included: - R92's Electronic Medical Record (EMR) documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), dementia (a progressive mental disorder characterized by failing memory and confusion), and encephalopathy (a broad term for any brain disease that alters brain function or structure). R92's admission Minimum Data Set (MDS) dated 10/16/23 documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R92 had impairment 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 identified a census of 115 residents. The sample included 26 residents with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration regarding Resident (R) 20 and R5'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 to these residents by hospice. This deficient practice created a risk of missed opportunities for services and delayed physical, mental, and psychosocial needs for these residents. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to 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 115 residents. The sample included 26 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to offer and/or obtain an informed declination for Resident (R) 35 and R75's Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections). This placed the residents at increased risk for complications related to pneumonia (a type of bacterial infection). Findings included: - R35's Electronic Medical Record (EMR) under the Immunization tab documented Refused for the PCV20 vaccination. R35's clinical record lacked evidence of an informed declination for R35 regarding the PCV20 vaccine. R75's EMR under the Immunization tab documented Refused for the PCV20 vaccination. R75's clinical record lacked evidence of an informed declination for R75 regarding the PCV20 vaccine. Upon request, the facility was unable to provide evidence of an informed declination of the PCV20 for R35 and R75. On 09/17 /24 at 10:22 AM Administrative Nurse E stated he had not had time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 114 residents. The sample included five residents with three residents reviewed for notification of changes. Based on observations, record review, and interviews, the facility failed to provide written notification, including the reason for the change, to Resident (R) 1 and her representative before she moved rooms. This deficient practice had the risk for miscommunication between R1/her representative and the facility and placed R1 at risk for decreased psychosocial well-being related to moving rooms without notice. Findings included: - R1 admitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), difficulty in walking, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning,…

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 106 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage, preparation, and handling. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 01/18/23 at 07:10AM an initial walkthrough of facility's kitchen was completed. A review of the kitchen's two hand washing sinks revealed the paper towel dispensers were empty with no clean hand drying option available. Next to the sink were several used yellow cloth towels lying on a table. An inspection of the kitchen's microwave revealed old food stains and residue splattered on the inside of the microwave. The clean storage rack for cooking pans contained a small saucepan with visible grease and food residue stuck on the inside of it. The kitchen's ice machine area had old food and trash directly underneath the machine and behind it. The kitchen's oven and flat-top grill was covered in grease and food residue. 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 four medication rooms. The facility failed to maintain refrigerator temperature logs in two of the four medication rooms used for medication and biological storage. This deficient practice placed the residents at risk ineffective medication and related side effects. Findings Include: - On 01/18/23 at 10:20AM an inspection of the facility's first floor medication room (100-121 hallway) revealed that the temperature log on the medication refrigerator were from August 2022. Licensed Nurse (LN) J stated that the temperature should be checked daily, but he did not know why the logs were not updated. On 01/18/23 at 11:00AM an inspection of the facility's second floor medication room (200-223 hallway) revealed an incomplete temperature log from January 2023. The only documented date the refrigerator was checked was 01/18/23. Licensed Nurse (LN) I stated that staff are checking the temperatures but may not be documenting them on the sheet. She stated that the refrigerator temperatures should be checked daily by the nurse assigned to the floor. On 01/24/22 at 02:05PM…

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 106 residents. The facility identified one resident positive with Carbapenem-resistant Acinetobacter baumannii (CRAB - highly contagious, drug resistant bacterial infection) on isolation precautions. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to transporting clean laundry. The facility additionally failed to store clean linens and hygiene supplies in a sanitary manner. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 01/18/23 at 07:45AM an initial walk-through of the facility was completed. A drawer containing incontinent briefs and bed pads was left open with an opened package of incontinent briefs out on top of the drawer on the second-floor hallway outside of R32's room. On 01/18/23 07:50AM a trash bag filled with trash sat on the floor of a resident's room. The bag remained on the floor at 09:05AM.…

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 106 residents. The sample included 25 residents. Based on observations, record review, and interviews, the facility failed to ensure adequate equipment was available and used during wheelchair locomotion for Resident (R) 7 and R30. This deficient practice had the risk for accidents and physical complications for affected residents. Findings included: - On 01/19/23 at 01:37 PM, an unidentified Certified Nurse Aide (CNA) propelled R7 in her wheelchair without foot pedals. R7 was unable to keep her feet off the floor during propulsion. On 01/23/23 at 10:51 AM, Activities Z propelled R30 in her wheelchair, without foot pedals. An unidentified licensed nurse (LN) took over propelling R30 to her room, R30's feet dragged on the floor. On 01/23/23 at 12:21 PM, R7 sat in her wheelchair in the doorway of another resident's room. CNA M turned R7's wheelchair around from the doorway, R7 stated to CNA M that she ran over R7's foot. CNA M propelled R7 in her wheelchair to the dining room, no foot pedals were utilized. On 01/23/23 at 01:17 PM, unidentified staff…

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

The facility identified a census of 106 residents. The sample included 25 residents with three residents reviewed for beneficiary notices review. Based on observation, record review, and interviews, the facility failed to provide Resident (R)309 with an Advanced Beneficiary Notice of Non-coverage (ABN-form 10055). This deficient practice placed R309 at risk for delay in care or missed services. Findings Included: - Review of R309's EMR indicated that her last covered day (LCD) for Medicare Part A services was 08/24/22. R309 was discharged from the facility on 12/08/22. On 01/18/23 a review of R309 beneficiary notifications revealed the facility or provider initiated her discharge from Medicare Part A services when she had benefit days remaining. The review indicated that an ABN form 10055 was not completed and provided to her upon discharge from the services. On 01/25/23 at 01:05PM Social Service X stated that she wasn't aware at the time of R309's discharge from services that the business office was no longer handling the Medicare notices and was not familiar with what forms should…

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 106 residents. The sample included 25 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to notify the state ombudsman of transfers and failed to provide a written notification of transfers with the required information to Resident (R) 20 and or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R20. Findings included: - R20 admitted to the facility on [DATE], transferred to the hospital on [DATE], readmitted to the facility on [DATE], transferred to the hospital on [DATE], and readmitted to the facility on [DATE]. The Diagnoses tab of R20's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin…

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 106 residents. The sample included 25 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy to Resident (R) 20 and R42 or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R20 and R42. Findings included: - R20 admitted to the facility on [DATE], transferred to the hospital on [DATE], readmitted to the facility on [DATE], transferred to the hospital on [DATE], and readmitted to the facility on [DATE]. The Diagnoses tab of R20's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of chest wall and dementia (progressive mental…

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

The facility identified a census of 106 residents. The sample included 25 residents with four residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide consistent bathing for Resident (R) 2. This deficient practice had the risk for poor hygiene and decreased self-esteem and dignity for R2. Findings included: - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth) and generalized muscle weakness. The Annual Minimum Data Set (MDS) dated 06/15/22, documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R2 required extensive assistance with one staff for bed mobility, transfers, dressing, and toileting; limited assistance with one staff for locomotion and personal hygiene; and total dependence with one staff for bathing. The Quarterly MDS dated 12/20/22, documented a BIMS…

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 106 residents. The sample included 25 residents. Based on observation, record review and interview, the facility failed to follow physician ordered daily weights for Resident (R) 81 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R81 at risk for excess fluid accumulation and physical complications. Findings included: - The electronic medical record (EMR) for R81 documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (HTN- elevated blood pressure), and cardiomyopathy (heart disease). The Annual Minimum Data Set (MDS) dated [DATE] documented R81 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R81 required limited to extensive assistance of one staff for her activities of daily living (ADLs). R81 was administered a diuretic on seven of seven…

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 106 residents. The sample included 25 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interviews, the facility failed to follow wound care as ordered by Consultant GG for Resident (R) 58. This deficient practice had the risk for delayed wound healing and physical complications for R58. Findings included: - R58 admitted to the facility at 06/10/22, discharged to hospital 11/25/22, readmitted [DATE], discharged [DATE], readmitted [DATE], and discharged to hospital 01/19/23. The Diagnoses tab of R58's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and pressure ulcer of sacral (large triangular bone between the two hip bones) region stage four (full-thickness skin and tissue loss- these sores extend below the subcutaneous fat…

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 106 residents. The sample included 25 residents with two residents sampled for positioning and limited range of motion (ROM) of extremities. Based on observations, record reviews, and interviews, the facility failed to ensure restorative care (care provided to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) was performed for Resident (R) 31. This deficient practice had the risk for a decline in functional mobility for R31. Findings included: - The Diagnoses tab of R31'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) affecting the left non-dominant side and generalized muscle weakness. The Annual Minimum Data Set (MDS) dated 10/16/22, documented R31 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 required extensive assistance with two staff for bed mobility and dressing; total dependence with two…

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 106 residents. The sample included 25 residents with six residents reviewed for accidents. Based on observations, record review, and interviews, the facility failed to implement fall prevention interventions after falls for Resident (R) 16 and R22, and failed to investigate to determine the root cause and implement an intervention for R54's non-injury fall. This deficient practice placed the affected residents at risk for injuries and accidents. Findings included: - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), and depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). 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 identified a census of 106 residents. The sample included 25 residents with two residents sampled for bowel and bladder review. Based on observations, record review, and interviews, the facility failed to provide a resident-centered toileting program for Resident (R) 42. This deficient practice had the risk for increased incontinence (lack of voluntary control over urination and defecation), skin breakdown, loss of dignity, and physical complications for R42. Findings included: - R42 admitted to the facility on [DATE]. The Diagnoses tab of R42's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic nephropathy (nerve damage that can occur with diabetes) and cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). The admission Minimum Data Set (MDS) dated 06/16/22, documented R42 had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 106 residents. The sample included 25 residents with three reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to offer and monitor intake of nutritional supplements for Resident (R) 54, who was at risk for weight loss. This placed the resident at further risk for unintended weight loss and malnutrition. Findingls included: - R54's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, difficulty in walking, and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R54 required extensive assistance of one staff member for activities of daily living (ADLs). The MDS documented no falls during the look back period. The Quarterly MDS dated 12/29/22 documented a BIMS score of eight 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 identified a census of 106 residents. The sample included 25 residents with one resident sampled for dialysis (procedure where impurities or wastes were removed from the blood) review. Based on observations, record review, and interviews, the facility failed to consistently complete dialysis communication sheets before and/or after dialysis which included vital signs and assessments for Resident (R) 31. This deficient practice had the risk for adverse outcomes and unwarranted physical complications for R31. Findings included: - The Diagnoses tab of R31's Electronic Medical Record (EMR) documented a diagnosis of chronic kidney disease stage four (disease where the kidneys were moderately or severely damaged and were not working as well as they should be to filter waste from the blood). The Annual Minimum Data Set (MDS) dated 10/16/22, documented R31 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 required extensive assistance with two staff for bed mobility and dressing; total dependence with two staff for transfers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 106 residents. The sample included 25 residents. Based on record review and interviews, the facility failed to ensure nursing staff possessed the knowledge and skills to assess neurological status (an evaluation of a person's neurological system to identify signs of disorders affecting the brain, spinal cord, and nerves) for Resident (R) 259 after she had an unwitnessed fall with head injury. This deficient practice placed R259 at risk for fall related complications and further injuries. Findings included: - R1 admitted on [DATE] and discharged [DATE]. The Diagnoses tab of R259's Electronic Medical Record (EMR) documented diagnoses of difficulty in walking, lack of coordination, generalized muscle weakness, and unsteadiness on feet. The admission Minimum Data Set (MDS) dated 02/28/22, documented R259 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R259 did not have any falls since admission. The Quarterly MDS dated…

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

The facility identified a census of 106 residents. The sample included 25 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide consistent dementia related assistance related to meals, wandering, and staff interactions with Resident (R)12. This deficient practice placed R12 at risk for impaired ability to achieve and/or maintain her highest practicable level of physical and emotional wellbeing. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of dementia, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dysphagia (swallowing difficulty), cognitive communication deficit, macular degeneration of both eyes (progressive deterioration of the retina), and history of falls. A review of R12's admission Minimum Data Set (MDS) dated 12/19/23 noted a Brief Interview for Mental Status (BIMS) score of eight…

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 106 residents. The sample included 25 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)22 was free from unnecessary psychotropic (affecting mood or thinking) medications when the facility failed to ensure R22's as needed (PRN) lorazepam (psychotropic antianxiety medication) had the required stop date of 14 days. This placed R22 at risk for unnecessary medications and side effects associated with lorazepam use. Findings included: - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of lack of coordination, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), and acetabulum fracture (is a break in the socket portion of the ball and socket hip joint). The Significant Change Minimum Data Set (MDS) dated…

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

The facility had a census of 108 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to deliver resident mail on Saturdays. Findings included: - On 06/09/21 at 11:30 AM, the surveyor met with five of the resident council members. During the meeting the residents verbalized mail was not always distributed to the residents on Saturdays. On 06/09/21 at 01:30 PM, observation of the front reception area revealed a mail carrier entering the facility. On 06/09/21 at 02:10 PM, Activity Staff (AS) Z stated there was an activity assistant who worked on Saturday and Sunday, and AS Z expected the mail to be delivered on Saturday. On 06/10/21 at 01:10 PM, AS Z stated she spoke with the weekend activity assistant and she verbalized she did not always get the Saturday mail distributed to the residents. On 06/10/21 at 01:20 PM, Administrative Staff A stated the weekend activity assistant was to deliver the mail to residents on Saturdays. The facility's Resident Rights policy, dated December 2020, documented the resident has the right…

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 108 residents. Based on observation, record review, and interview, the facility failed to provide a dietary manager to carry out the functions of food and nutritional services for the 103 resident who residents who received meals from the facility kitchen. Findings included: - On 06/09/21 at 11:45 AM, observation revealed Dietary Staff (DS) BB participated and provided oversight of the lunch meal preparation and service. On 06/07/21 at 10:30 AM, DS BB stated he was not a certified dietary manager, had passed all of his classes, and was waiting for a testing time to be scheduled so he could become certified. On 06/10/21 at 01:30 PM, Administrative Nurse D stated DS BB was not certified, but had paid for his test, and was waiting for a test date to become certified. The facility's Director of Food and Nutritional Services policy, dated 2017, documented the director of food and nutrition services will be responsible for the safe, sanitary, economical, and nutritional operation of the food and nutrition services department. The director of food and nutrition…

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 108 residents. Based on observation, record review, and interview, the facility failed to prepare, store, and serve meals under sanitary conditions for the 103 residents who received meals from the facility kitchen. Findings included: - On 06/07/21 at 09:45 AM, observation during initial tour of the kitchen revealed the following: Food debris, dried brown crumbs, all over a large bag of sugar. Food debris, dried brown crumbs, all over the tops of Heinz Minestrone Soup cans. Floor in the dry storage area with food debris and dried brown crumbs all over the floor Walk-in freezer floor covered with dried food debris and brown crumbs. Walk-in refrigerator with food debris on the floor, onion skins, brown crumbs, and a wet brown sticky substance. Outside of the side by side refrigerator doors were covered with dried food debris. Inside the side by side refrigerator with a dried on brown food spill on the bottom of the refrigerator. On 06/09/21 at 12:15 PM, observation revealed Dietary Staff (DS) DD served food in the lower dining room. DS DD used gloved hands…

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 108 residents. The sample included 22 residents, with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff reported an allegation of rape to administrative staff after Resident (R) 64 made a allegation of rape to a licensed nurse, who failed to report it to administrative for 24 hours. - R64's Physician Order Sheet, dated 05/28/21, documented diagnosis of cerebral infarction (damage to the tissues in the brain due to a lack of oxygen to the area), and cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had short- and long-term memory loss and moderately impaired cognitive skills. The MDS documented the resident required one staff assistance with bathing. The Activities of Daily Living Care Plan, dated 01/14/21, directed two staff to assist…

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 108 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to complete a Comprehensive admission Assessment for one of 22 sampled residents, Resident (R) 164. Findings included: - R164's medical record documented the facility admitted the resident on 05/03/21. The facility's Electronic Health Record system documented the Assessment Reference Date (ARD) for the admission Minimum Data Set (MDS), as 05/10/21. On 06/08/21, review of R164's medical record-MDS revealed the admission MDS had not completed. On 06/09/21 at 7:40 AM, observation revealed the resident sat in his wheelchair in his room. On 06/09/21 at 01:50 PM, Administrative Nurse E verified she was responsible for completing MDS assessments on the residents in the facility. Administrative Nurse E verified R164's admission MDS was not completed. On 01/10/21 at 08:30 AM, Administrative Nurse D verified she expected the MDS assessments to be completed in a timely manner. The facility's Minimum 3.0 Completion policy, dated 02/01/20,…

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 108 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure the timely completion of Quarterly Minimum Data Sets (MDS) for Resident (R) 12 and R76. Findings included: - R76's Quarterly MDS had an Assessment Reference Date of 05/18/21 and was due to be completed by 06/01/21. On 06/10/21 the Quarterly MDS had not been completed. According to the Resident Assessment Instrument (RAI), the Quarterly MDS must be completed 14 calendar days from the Assessment Reference Date. On 06/10/21 at 01:44 PM, Administrative Nurse E stated that May had been a busy month, she just got behind and did not get the MDS's done. On 06/10/21 at 02:15 PM, Administrative Nurse D stated the MDS's should have been completed according to the MDS completion dates. The MDS 3.0 Completion policy dated 02/01/20, documented residents are assessed using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Persons completing part of the assessment must attest…

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 108 residents. The sample included 22 residents, with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services as care planned for one of three sampled residents, Resident (R) 45. Findings included: - R45's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, required limited assistance of one staff for personal hygiene, and physical help of one staff for bathing. The ADL Care Area Assessment (CAA), dated 08/05/20, documented the resident required supervision with her ADL cares for safety concerns and oversight. The ADL Care Plan, dated 05/25/21, documented the resident required physical assistance of one person to transfer in and out of the shower, able to shower with supervision, and often refused showers. The care plan directed staff to remind the resident the importance of hygiene, and offer the resident washcloths and soapy water for sponge…

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 108 residents. Based on observation, interview, and record review, the facility failed to label insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened for Resident (R) 96, failed to discard an expired insulin pen for R105, and failed to discard expired stock medications on two of four units. Findings included: - On 06/07/21 at 10:00 AM, observation of the medication cart on Reflection Unit revealed R96's Humalog (fast acting insulin starts to work in 15 minutes) flex pen, and Lantus (long acting insulin up to 24 hours) flex pen, lacked a date opened. On 06/07/21 at 10:10 AM, Licensed Nurse (LN) G verified R96 received insulin daily, and the insulin flex pens lacked a date opened. On 06/08/21 at 08:50 AM, observation of the medication cart on [NAME]/Jayhawks Hall revealed R105's Basaglar (long acting insulin peak effect at 12 hours) flex pen, opened 05/08/21, and expired 06/04/21, still in use. Continued observation revealed the following…

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.