Tonganoxie Terrace

The facility had a census of 70 residents. The sample included 18 residents, with three residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 20 and R2 with written information regarding the facility's bed hold policy when the residents were transferred to the hospital and failed to notify the State Long Term Care Ombudsman (LTCO) of their facility-initiated discharge to the hospital.Findings include: - Resident (R) 20's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), 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), patient's noncompliance with other medical treatment and regimen, dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances 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 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent further injuries to the lower extremities of Resident (R) 3 and R44's smoking activity.Findings included:- R3's Electronic Medical Record (EMR) recorded diagnoses of adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), congestive heart failure (CHF -a condition with low heart output and the body becomes congested with fluid), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), severe protein-calorie malnutrition, lymphedema (swelling caused by accumulation of lymph), muscle weakness, unsteadiness on feet, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle…

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 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide necessary services for two of six residents reviewed for activities of daily living (ADL): Resident (R) 69 and R20.Findings included:- R69's Electronic Medical Record (EMR) documented R69 had diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and sequelae of cerebral infarction (commonly known as a stroke, when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts). R69's Quarterly Minimum Data Set (MDS) dated [DATE] documented R69 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R69 required substantial, maximal staff assistance with showering. R69's Care Plan, revised 12/25/25, documented R69 required substantial staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide care and treatment in accordance with professional standards of practice when the staff failed to provide Resident (R) 6 treatment for low blood sugar before transferring to the hospital. The facility failed to provide documentation related to R3's and R20's transfer to the hospital. Findings included:- R6's Electronic Medical Record, (EMR) documented R6 had a diagnosis of Type 2 Diabetes Mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented R6 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The MDS documented that R6 received insulin (a hormone that lowers the level of glucose in the blood) for seven days during the look-back period. R6's Care Plan revised…

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 70 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to fully investigate Resident (R) 25's unwitnessed fall to identify causative factors and implement interventions to prevent further falls. The facility further failed to accurately identify R44's tobacco use and assess his ability to safely smoke independently. Findings included: - R25's Electronic Medical Record (EMR) documented the resident had diagnoses Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hypoxia (inadequate supply of oxygen), hypertension (HTN -elevated blood pressure), and muscle weakness. R25's admission Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) of 00, indicating severely impaired cognition. The MDS recorded the resident was dependent on staff 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 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to establish and implement a system to accurately reconcile the disposition of controlled medications and failed to account for all controlled substances.Findings included:- On 01/29/26 at 10:00 AM, observation of a controlled substance reconciliation revealed one bottle of morphine (narcotic pain medication with high potential for abuse) 20 milligrams (mg) per milliliter (ml) concentrate was unaccounted for.Review of the Pharmacy Spreadsheet revealed the morphine was listed with a prescription number, medication name and date of delivery. The missing medication belonged to Resident (R) 16.On 01/27/26 at 02:55 PM, Licensed Nurse (LN) K stated that at the end of her shift, she counted the narcotics with the oncoming nurse and compared them with the controlled drug administrative record. LN K stated that if the count was off, staff would recount, and if it was still inaccurate, the nurses reported the discrepancy to the director 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 identified a census of 67 residents. The sample included nine residents, with two residents reviewed for involuntary discharge. Based on record review and interviews, the facility failed to include the required information on an emergency discharge notice for Resident (R) 1 and on a 30-day discharge notice for R2. This deficient practice had the risk for miscommunication between the facility and resident/family, a possible missed opportunity for healthcare services, and involuntary discharge for R1 and R2.Findings included:- R1 admitted to the facility on [DATE] and discharged to the hospital on [DATE].R1's Electronic Medical Record (EMR) documented diagnoses of other Schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diffuse traumatic brain injury (TBI- an injury to the brain caused by external forces) with a loss of consciousness, affective mood disorder (category of mental health 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 67 residents. The sample included nine residents, with three residents reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of stay for Residents (R) 2, R3, and R4. This deficient practice had the risk for miscommunication of services received during the stay in the facility and if post-discharge care needs for the affected residents.Findings included:- R2 admitted to the facility on [DATE] and discharged on 07/31/25.R2's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder), repeated falls, and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS) dated 03/04/25, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R2's overall goal was to remain in the facility, and she had no discharge plan.The Quarterly 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.

The facility identified a census of 67 residents. The sample included nine residents, with three residents reviewed for bathing. Based on observations, record review, and interviews, the facility failed to provide consistent bathing for Residents (R) 5 and R6. This deficient practice had the risk of poor hygiene and decreased self-esteem and dignity for the affected residents.Findings included:- R5's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and unsteadiness on feet.The admission Minimum Data Set (MDS) dated 03/14/25 documented R5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R5 required substantial/maximal assistance with bathing.The Quarterly MDS dated 06/04/25, documented R5 had a BIMS score of 13, which indicated intact cognition. R5 required partial/moderate assistance with bathing.The Functional Abilities Care Area Assessment (CAA) dated 03/21/25 documented R5 reported weakness to upper and lower extremities as well as decreased range of motion (ROM- the full movement potential of a…

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

The facility had a census of 85 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). The facility further failed to ensure adequate infection control practices related to catheter (a tube inserted into the bladder to drain urine) care. These deficient practices placed the residents at increased risk for transmission of infectious diseases. Findings included: - On 03/20/24 at 02:39 PM, Maintenance Staff U and Administrative Staff A reported they were not aware of a required water management program to prevent waterborne pathogens (organisms causing disease) and verified the facility had no current program. The facility's Water Management Plan policy, dated 04/01/22, documented the intent and content of this policy as one…

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

The facility had a census of 85 residents, with 18 residents included in the sample. Five nurse aide staff were reviewed for the required training. Based on observation, record review, and interview, the facility failed to provide the required 12 hours of in-service education for Certified Medication Aide (CMA) R, CMA RR, and CMA SS. This deficient practice placed the residents at risk of receiving impaired care. Findings included: - A review of the facility's 12-hour annual in-service documentation revealed CMA R, CMA RR, CMA SS, and CNA P lacked documentation of the required 12 hours of in-service education. On 03/20/24 at 10:34 AM, Administrative Nurse D stated she served the role of Director of Nursing since 11/2023. Administrative Nurse D stated she should have a skills fair for in-service and competency assessment related to nursing care. Administrative Nurse D verified the lack of evidence the sampled CNA staff had the required 12 hours of in-service. The facility's Competency of Nursing Staff policy, undated, documented all nursing staff must meet the specific competency…

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 85 residents. The sample included 18 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure an environment free from preventable accident hazards for Resident (R) 29 who burned his fingers his fingers while smoking. The facility further failed to assess R41 for the ability to smoke safely and failed to provide interventions to prevent injuries and falls for R46 and R31. These deficient practices placed the residents at risk for injuries related to accidents. Findings included: - R29's Electronic Medical Record (EMR) documented R29 admitted to the facility 11/29/23 with diagnoses of neuromuscular dysfunction of bladder (lacks bladder control due to brain, spinal cord, or nerve problems), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and pneumonia (inflammation of the lungs). The Quarterly Minimum Data Set (MDS), dated [DATE], 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 had a census of 85 residents. The sample included 18 residents, with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the Consultant Pharmacist (CP) failed to identify and report medications administered outside of physician-ordered parameters for Resident (R) 15, R31, and R6 and failed to identify and report an inappropriate indication for Seroquel (an antipsychotic medication used to treat severe mental disorders) for R4. This placed the residents at risk for adverse side effects, physical decline, and unnecessary medications. Findings included: - R15's Electronic Medical Record (EMR) recorded diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), hypertension (high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), hypotension (low blood pressure), and heart failure (a condition with low heart output and the body becomes congested with…

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 85 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to date Resident(R)34 and R13's insulin (a hormone that allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R38's insulin flex pen when outdated. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 03/13/24 at 08:25 AM, observation of the facility's 300 and 400 medication carts revealed the following: R34's Humalog (fast-acting insulin) flex pen lacked an open date and discard date. R13's Humalog lacked an open and discard date. R38's Lantus (long-acting insulin) vial had an opened date of 02/06/24 (discard date of 03/05/24). On 03/20/24 at 09:00 AM, Administrative Nurse D verified the nurses were to date the insulin when opened and discard the outdated insulin. Administrative Nurse D said the night nurse should check the carts for expired medications and every nurse that administered medications should review the insulin to be sure…

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 85 residents. The sample included 18 residents with four reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified injuries of unknown origin as potential allegations of abuse and report to the administrator to investigate. This placed the residents at risk for unidentified and ongoing abuse and/or mistreatment. Findings included: - R46's Electronic Medical Record (EMR) documented the resident had diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid,) diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk ), dementia (progressive mental disorder characterized by failing memory, and confusion), and anxiety. R46's Quarterly Minimum Data Set (MDS) dated [DATE], recorded the resident had 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 had a census of 85 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)46's injuries of unknown origin to rule out possible abuse or neglect. This placed the residents at risk for unidentified and ongoing abuse or neglect. Findings included: - R46's Electronic Medical Record (EMR) documented the resident had diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid,) diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk ), dementia (progressive mental disorder characterized by failing memory, and confusion), and anxiety. R46's Quarterly Minimum Data Set (MDS) dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) of three indicating severely…

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 85 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop comprehensive care plans for Resident (R)31, R77, and for R29. This placed the residents at risk for impaired care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R31 had severely impaired cognition and required substantial/maximum assistance for toileting, dressing, personal hygiene, partial/moderate assistance with transfers, and mobility. R31 had no functional limitations, had one fall with injury since admission, received insulin, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 85 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan with interventions to address Resident (R) 30's pain and R46's skin tears. This deficient practice placed R30 and R46 for impaired care due to uncommunicated care needs. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of alcohol dependence, chronic pain in the right shoulder, and dorsalgia (physical discomfort occurring anywhere on the spine or back). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R30 had no rejection of care behavior. The MDS documented R30 had no range of motion (ROM) impairment, used a wheelchair, and required partial moderate assistance for bathing. The MDS documented R30 received scheduled and as-needed (PRN) pain management but no non-medication pain relief for almost constant…

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 85 residents. The sample included 18 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to provide necessary services to maintain good personal hygiene including bathing for Resident (R) 4, R41, and R30. This placed the residents at risk for impaired health and decreased psychosocial well-being. Findings included: - R4's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat). R4's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R4 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired 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 85 residents. The sample included 18 residents with five reviewed for urinary catheter (insertion of a catheter into the bladder to drain the 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 care and services to prevent potential infection of the urinary system for Resident (R) 29 and R17 during care for their urinary catheters and failed to promote dignity with a privacy bag. This deficient practice placed R29 and R17 at risk for urinary infections and other catheter-related complications. Findings included: - R29's Electronic Medical Record (EMR) documented diagnoses of neuromuscular dysfunction of the bladder (lacks of bladder control due to brain, spinal cord, or nerve problems), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), urinary tract infection (UTI-an…

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 85 residents. The sample included 18 residents with one reviewed for pain. Based on observation, interview, and record review the facility failed to provide non-medicinal pain relief measures and promote effective pain management for Resident (R) 30, who experienced almost constant severe pain. This deficient practice placed R30 at risk for ongoing severe pain and impaired quality of life. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of alcohol dependence, chronic pain in the right shoulder, and dorsalgia (physical discomfort occurring anywhere on the spine or back). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R30- had no rejection of care behavior. The MDS documented R30 had no range of motion (ROM) impairment, used a wheelchair, and required partial moderate assistance for bathing. The MDS documented R30 received scheduled and as-needed (PRN)…

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 85 residents. The sample included 18 residents with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial well-being for Resident (R)26 and R77. This placed the residents at risk for decreased quality of life. Findings included: - The Electronic Medical Record (EMR) for R26 recorded diagnoses of mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions). cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and 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…

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 85 residents. The sample included 18 residents, with eight reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars outside of ordered parameters for Resident (R) 31 and further failed to monitor R31's blood pressure before administration of medication for high blood pressure. The facility failed to hold blood pressure medication and insulin (medication that lowers the level of glucose [a type of sugar] in the blood) when the medication was out of the physician-ordered parameters for R6. This placed the residents at risk for adverse effects related to medication. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 85 residents. The sample included 18 residents, with eight reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)4's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R4 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R4's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with…

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 85 residents. The sample included 18 residents with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 15. This deficient practice placed the resident at risk for adverse medication reactions and physical decline. Findings included: - R15's Electronic Medical Record (EMR) recorded diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), hypertension (high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), hypotension (low blood pressure), and heart failure (a condition with low heart output and the body becomes congested with fluid). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15 had moderately impaired cognition and required substantial/maximum assistance for toileting, showering, and personal hygiene. R15 required supervision 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 68 resident. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food in a sanitary condition for the 68 residents who resided in the facility and received meals from the facility kitchen, placing them at risk for food borne illness. Findings included: - On 08/31/22 at 08:35 AM during the initial tour of the kitchen observations revealed the following: The steam table water pans had brown water, food debris and brown sediment on the bottom and around the inside edges of the pan. The large silver refrigerator temperature log for August 2022 lacked documentation for 10 days out of 31 days of the month. The large silver freezer temperature log for August 2022 lacked documentation for 10 days out of 31 days of the month. The overhead fluorescent lights had dead bugs. The kitchen ice machine had a sticker on the front that read Ice machine monthly cleaning. The sticker had staff initials for January and March only.…

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 68 residents. The sample included 21 residents. Based on observation, record review and interview the facility failed to ensure their (QAA) Quality Assessment and Assurance Committee adequately identified deficient areas of practice and to develop and implement appropriate plans of action to correct the deficient practices for the 68 residents residing in the facility. Findings included: Based on observation, record review and interview, the facility failed to notify the physician with a change in the resident behavior/mood, a resident refusing medication, and unresponsive episode. Refer to 550. Based on observation, record review and interview, the facility failed to provide the resident the choice to continue with Medicare skilled services. Refer to 582. Based on observation, record review and interview, the facility failed to thoroughly investigate post unwitnessed resident falls. Refer to 610. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for a resident that had displayed behaviors 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 68 residents. Based on observation, record review and interview the facility failed to adhere to infection control policies during an outbreak of COVID-19 (highly contagious, potentially life-threatening respiratory virus), which placed the resident and staff at risk for possible exposure of respiratory illness. Findings included: - On 09/01/22 at 12:17 PM observation reveal Dietary Staff (DS) DD observed delivering meals to Droplet Isolation room of a COVID-19 positive resident. A sign was posted on the door giving instructions on PPE use (gown, gloves, face/eye protection, KN95 mask and shoe covers). The room also had a plastic tote with PPE supplies place outside the room doorway. DS DD entered the room only wearing a KN95 mask. DS DD exited the room and returned to the kitchen area. DS DD verified she had not worn full PPE in the COVID-19 isolation room and was not aware she had to. Administrative Staff A escorted DS out of area explaining isolation precautions. On 09/06/22 at 02:30 PM observation revealed Housekeeper U clean a COVID-19 droplet…

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 68 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control. Findings included: -On 08/31/22 upon initial entrance of the facility for recertification survey, Administrative Staff A identified Administrative Nurse E as the IP. On 09/06/22 at 04:12 PM Administrative Nurse E reported she lacked certification as an Infection Preventionist. On 09/09/22 the facility provided certificates of completion of some modules ( one through four) of Infection Preventionist training by Administrative Staff A but did not include all modules required for certification. The facility's Infection Control Preventionist policy, dated 08/2022, documented individual (s) as the infection preventionist who are responsible for the facility Infection Control program. The Infection Control Preventionist is to have completed specialized training…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to notify the physician for Resident (R) 30, who had multiple days of refusing her medications for several months; R47, who had a history of seizures (a sudden, uncontrolled electrical disturbance in the brain) and had an unresponsive episode; R37, who had a history of sexual behavior and had an alleged incident with another resident, and R59, who had an unresponsive episode in the shower. This placed the resident's at risk for further physical, emotional, and mental decline. Findings included: - The Electronic Medical Record (EMR) for R30 had diagnoses of lupus (a chronic, inflammatory, connective tissue disease that can affect the joints and many organs), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), anoxic brain damage…

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 68 residents. The sample included 21 residents with eight 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 seven of the eight residents reviewed for ADLs, Resident (R)8, R55, R19, R23, R30, R67 and R15. This placed the residents at risk for poor personal hygiene. Findings included: - R8's Physician's Order Sheet, dated 08/01/22, recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion,) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) and major depressive disorder (major mood disorder.) R8's Annual Change Minimum Data Set (MDS), dated [DATE], recorded the resident 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 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to properly date and store insulin pens (medications used to treat a chronic condition that affected the way the body processed blood sugar) label, and failed to store drugs and biologicals at a safe room temperature in the south hall medication room. This deficient practice had the risk of physical complications and ineffective treatment for affected residents. Findings included: - On [DATE] at 08:35 AM Certified Medication Aide (CMA) R unlocked the medication room. The medication room temperature was warm, and the handwashing sink did not work. The August Refrigerator, Freezer and Room Temperature Log recorded only five days of 31 days of room temperature which read of 80 degrees Fahrenheit (F) and refrigerator temperature reading of 39 degrees F. On [DATE] at 08:45 AM Licensed Nurse (LN) G was present at the south hall treatment cart when observation 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.

The facility had a census of 68 residents. The sample included 21 residents of which five where reviewed for immunization status. Based on record review and interview the facility failed to offer and provide and/or obtain informed refusals for Influenza and Pneumococcal vaccinations for Resident (R) 15, R25, R39, R67 and R47. This placed the affected residents increased risk for illness and infection. Findings included: - R15's clinical record lacked evidence the pneumococcal vaccine was offered, or an informed refusal was obtained. R25's clinical record lacked evidence the pneumococcal vaccine was offered, or an informed refusal was obtained. R39's clinical record lacked evidence the pneumococcal vaccine was offered, or an informed refusal was obtained. R67's clinical record lacked evidence the pneumococcal vaccine was offered or an informed refusal was obtained. R47's clinical record lacked documentation of influenza history and lacked evidence the pneumococcal vaccine was offered, or an informed refusal was obtained. On 09/06/22 at 04:12 PM Administrative Nurse D stated the…

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

The facility identified a census of 68 residents. The sample included 21 residents with five residents reviewed for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccination review. Based on record reviews and interviews, the facility failed to offer and administer or obtain a signed declination for the COVID-19 booster vaccination for Resident (R) 15, R25, R39, R67 and R47. This deficient practice placed the residents at increased risk for unwarranted complications related to COVID-19 and the risk to spread illness and infection to the residents. Findings included: -Resident (R) 15 clinical record lacked evidence of an offer and/or informed refusal for COVID-19 second primary dose and second booster documentation. R25's clinical record lacked evidence of an offer and/or informed refusal for COVID-19 second booster. R39's clinical record lacked evidence of an offer and/or informed refusal for COVID-19 primary and second COVID-19 booster. R67's clinical record lacked evidence of an offer 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.

The facility had a census of 68 residents. The sample included 21 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R) 39, R49 and R320 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services. This placed the residents at risk to make uninformed decisions about their skilled care Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility lacked documentation staff provided R39, or her representative, the completed form 10055…

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 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to develop a care plan for Activities of Daily Living (ADLs) for Resident (R) 47. This placed the resident at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R47 listed diagnoses of epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acquired absence of left leg below the knee (one or more limbs are surgically removed). The admission 5 -day Medicare Minimum Data Set, (MDS), dated [DATE], documented R47 had intact cognition and was dependent upon two staff for transfers. R47 required extensive assistance of two staff for bed mobility, dressing, toileting, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 68 residents. The sample included 21 residents of which three were reviewed for falls and behaviors. Based on observation, record review, and interview, the facility failed to revise Resident (R)30's care plan for medication refusals and failed to place resident centered interventions to prevent falls on the care plan for R47 and R15. This placed the residents at risk for physical and mental injury due to unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R30 had diagnoses of lupus (a chronic, inflammatory, connective tissue disease that can affect the joints and many organs), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), anoxic brain damage (caused by lack of oxygen to the brain), encephalopathy (any diffuse disease of the brain that alters brain function or structure), anxiety (mental or emotional reaction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 68 resident. The sample included 21 residents. Based on observation, record review and interview, the facility failed to provide staff support to assist and maintain activities of daily living for Resident (R) 15, which placed the resident at risk for decline and injury. Finding included: -The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of hypertension, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), old myocardial infarction (heart attack), post-traumatic stress disorder (PTSD- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture), amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscle and impacts…

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 68. The sample included 21 residents with two residents reviewed for quality of care. Based on observation, interviews and record review the facility failed to ensure staff provided assessment, ongoing monitoring and physician involvement for Resident (R) 59 who had an unresponsive episode and R47 who had seizure activity. This placed the residents at increased risk for physical complication, unidentified adverse outcomes, and delayed treatment. Findings Included: - R59's Medical Diagnosis section within the Electronic Medical Record (EMR) included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) with psychotic(any major mental disorder characterized by a gross impairment in reality testing) features, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized…

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 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to investigate a root cause analysis to prevent falls for two of four residents reviewed for falls, Resident (R) 15 and R47. This deficient practice placed the resident at risk for further falls and injury. Findings included: - -The Medical Diagnosis section withing R15's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), old myocardial infarction (heart attack), and amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscle and impacts physical function, also known as [NAME] Gehring's disease). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R15 had intact cognition, required supervision of one staff with…

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 68 residents. The sample included 21 residents with six residents reviewed for nutritional status. Based on observation, record review, and interview, the facility failed to monitor, address and ensure interventions and assistance was provided to prevent a continued weight loss for Resident (R) 15, who required assistance with eating. This placed R15 at risk for continued unintentional weight loss and impaired nutritional status. Finding included: -The Medical Diagnosis section withing R15's Electronic Medical Records (EMR) included diagnoses of hypertension, chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), old myocardial infarction (heart attack), post-traumatic stress disorder (PTSD- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat,…

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 68 residents. The sample included 21 residents, with one reviewed for dialysis (process of removing 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 interview, the facility failed to perform physical assessments on Resident (R) 23, after his return from dialysis. This placed the resident at increased risk for unidentified complications related to dialysis or delay in treatment. Findings included: - The Electronic Medical Record (EMR) for R23 documented diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), end stage renal disease (kidneys cease functioning on a permanent basis), and celiac disease (the small intestine is hypersensitive to gluten [a mixture of two proteins] leading 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 had a census of 68 residents. The sample included 21 residents with three reviewed for behavioral and/or emotional status. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)30. This placed the resident at risk for unaddressed and ongoing behavioral health issues and impaired psychosocial wellbeing. Findingls inlcuded: - The Electronic Medical Record (EMR) for R30 had diagnoses of lupus (a chronic, inflammatory, connective tissue disease that can affect the joints and many organs), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), anoxic brain damage (caused by lack of oxygen to the brain), encephalopathy (any diffuse disease of the brain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 68 residents. The sample included 21 residents, with one reviewed for medication availability. Based on record review and interview, the facility failed to ensure availability of physician ordered medications for Resident (R)321. This placed the resident at risk for ineffective medication regimen and physical decline. Findings included: - R321's Physician Order sheet, dated 03/19/22 documented diagnoses chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock,) bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), peritoneal abscess (tissue that lines the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility at a census of 68 residents. The sample included 21 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 59 consistently received medications as ordered by the physician and failed to follow up on consistent refusal of physician ordered medications for R30. This placed the residents at increased risk for ineffective medication therapy. Findings included: - R59's Medical Diagnosis section within the Electronic Medical Record (EMR) included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) with psychotic(any major mental disorder characterized by a gross impairment in reality testing) features, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity…

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 68 residents. The sample included 21 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R)8's Seroquel (an antipsychotic -medication used to treat any major mental disorder characterized by a gross impairment in reality testing), failed to report to ther physician multiple refusals of R30's psychotropic (altering mood or though) medication and failed to monitor behaviors for R59 who received multiple psychotropic medication including an antipsychotic. This placed the residents at increased risk for negative side effects related to medications and unnecessary psychotropic medication use. Findings include: - R8's Physician's Order Sheet, dated 08/01/22, recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) dementia with behavioral disturbance (progressive mental disorder characterized by…

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.