Azria Health Wichita

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 68. The sample included 4 residents in the sample for reviews of misappropriation of medications. Based on observations, interview and record review the facility failed to ensure Resident (R) 1 remained free from misappropriation of medications, when on 02/04/24 Licensed Nurse D removed R1's second card of three with 45 tablets of hydrocodone (medications used for pain) 10-325 milligrams (mg) from the facility. The deficient practice placed R1 at risk for missed medication, unrelieved pain, and further misappropriate of medications. Findings included: - The Physicians Orders date 03/4/25 for R1 revealed the following diagnosis paraplegia incomplete paralysis characterized by motor or sensory loss in the lower limbs and trunk) muscle spasms (involuntary contractions of a muscle) lupus (autoimmune disease is only condition hat causes the immune system believe the body's tissue are foreign pathogens and attacks the tissues) The Quarterly Minimum Data Set (MDS) dated [DATE] 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 reported a census of 64 residents. The facility identified one central kitchen with two satellite kitchens and two dining areas. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility. Findings included: - Initial tour of the kitchen on 04/09/24 at 09:05 AM with Dietary Staff H, revealed the following areas of concerns: 1. In the west kitchen, Dietary Staff Y performed tasks in the kitchen and had long hair exposed below the level of her buttocks with hair restraint device covering only the top of her head. 2. In the west kitchen, in the refrigerator, a bottle of orange juice with a factory expiration date of 09/29/23. 3. In the west kitchen, in the freezer, a package of hotdog buns unsealed and opened to air. 4. In the west kitchen freezer, a package of miscellaneous bread products unsealed and opened to air. 5. In the main kitchen food preparation area, four cutting boards with non-cleanable surfaces. 6. In the main…

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 64 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - Initial tour of the kitchen facilities on 04/09/24 at 09:50 AM with Dietary Staff H, revealed that the outside dumpster area was littered with medical waste that included soiled bandages and disposed gloves and that the dumpster lid was in the open position. On 04/09/24 at 09:53 AM, Dietary Staff H stated that she was unaware of the requirement that kitchen staff were responsible for the cleanliness of the area around the dumpster or that the dumpster lid was to always remain closed. On 04/09/24 at 09:58 AM, Administrative Nurse B stated that her expectation was for all staff that takes trash to the dumpster to ensure that the area around the dumpster is kept free of any debris and that the lid of the dumpster should be closed at all times. The presence of medical waste on the ground outside the dumpster was 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.

The facility reported a census of 64 residents and identified 11 residents as confused and self-mobile. Based on observation, record review, and interview, the facility failed to ensure the environment was free of accident hazards for these 11 residents, including failure to keep hazardous chemicals out of reach. Furthermore, the facility failed to maintain a safe environment when staff utilized a gait belt to secure Resident (R)1's door to remain in the open position. Findings included: - On 04/09/24 at 11:44 AM, observation revealed R1's room contained an unidentified, unlabeled spray bottle that hung from the foot of the bed. R1 identified the contents as a cleaning agent for staff use when staff emptied her catheter bag and if any urine spilled onto the floor. On 04/09/24 a 11:46 AM, observation of R1's bathroom revealed a bottle of Fabuloso cleaning agent with the manufacturer label documented Keep out of reach of children. The cleanser sat on the counter next to mouthwash and personal hygiene products. On 04/10/24 at 10:13 AM, observation of R1's bathroom revealed a bottle 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 - Resident (R) 25's diagnoses included neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and urinary tract infection (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent for all cares and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The 11/03/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/03/23, revealed the resident required a urinary catheter. The care plan, dated 10/13/23, revealed the resident required a urinary catheter. Revision of the care plan revealed on 04/10/2024, the resident required Enhanced Based Precautions (EBP) related to wound and catheter. Staff were to wear gloves and gowns for all dressing,…

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 64 residents and identified 11 residents as confused and self-mobile. Based on observations, interviews, and record review, the facility failed provide a safe environment for 11 residents by the failure to ensure that Resident (R)25 and R1's rooms remained free of unsecured medications, when the facility failed to secure medications in both residents' rooms. This deficient practice had the potential to create an accidental ingestion of medications to these confused, mobile residents. Findings included: - The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body). R25's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R25 was…

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

The facility reported a census of 64 residents. The facility identified one central kitchen with two satellite kitchens and two dining areas. Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature. Findings included: - On 04/11/24 at 09:00 AM, test trays were requested from Dietary Staff H for the noon meal service, one from each of the satellite kitchens. On 04/11/24 at 12:24 PM Dietary Staff H provided surveyors with a meal tray from the west kitchen with all foods measured by Dietary Staff H above appropriate temperature of 135 degrees Fahrenheit (°F) for food service. All foods were sampled for palatability, and all were acceptable except for the tater-tots which tasted stale and freezer burnt. On 04/11/24 at 12:48 PM Dietary Staff Z provided surveyors with a meal tray from the east kitchen with all foods measured by Dietary Staff Z. The tater-tots measured at 130.9 °F and popcorn shrimp measured at 132 °F. Dietary Staff Z stated that all foods were to be served at 135°F 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 reported a census of 64 residents which included 16 residents sampled. Based on observation, interview and record review, the facility failed to provide a sanitary and safe environment to prevent cross contamination and infection related to provision appropriate use of personal protective equipment (PPE) for 13 residents (R)1, R 4, R 11, R 19, R 25, R 26, R 37, R 38, R 40, R 48, R 50, R 55, and R 57, which required enhanced barrier precautions to be in place and available for nine residents with catheters (R 1, R 26, R 11, R 55, R19, R 37, R 50, R 04, R 25), five residents with wounds (R 38, R 40, R 19, R 50, and R 25), two residents with percutaneous enteral gastrostomy tube (PEG- artificial opening through the abdominal wall where a catheter is placed to supply nutrition), (R 37 and R 48), four residents (R 55, R 38, R 48, and R 57 of the 13 identified residents that required enhanced barrier precautions during care received therapy. Additionally, the facility failed to provide safe and sanitary…

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 64 residents that included 16 residents sampled. Based on observation, record review and interview, the facility failed to maintain Resident (R)20's dignity when staff talked to the resident in a demeaning manner, for R25, when staff failed to close a window when providing incontinence cares, and for R50, that failed to cover the resident's urinary catheter collection bag when in public view. Findings included: - The undated Physician Orders, for Resident (R)20 documented diagnoses which included cognitive communication deficit, cerebral vascular accident (stroke is a sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), traumatic brain injury, repeated falls, fractures (broken bones) and other multiple traumas. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident with a Brief Mental Status Interview, (BIMS) score of 13, indicating cognitively intact. The resident did not…

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 64 residents, which included 16 residents sampled, including one resident reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interview, the facility failed to ensure Resident (R)11's call light remained within his reach. Findings included: - The Electronic Health Records (EHR) for Resident (R)11 included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), generalized weakness, aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and rheumatoid arthritis (RA - a chronic inflammatory disease that affected joints and other organ systems). The 12/23/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates intact cognition. R11 required substantial assistance…

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 64 residents which included 16 residents sampled for review. Based on observation, interview and record review, the facility failed to track grievances through to their conclusions and provide prompt efforts to resolve a grievance filed by a resident (R)20 regarding the behavior of staff, offer or provide written grievance decisions to the resident regarding his or her grievance, and to offer or provide a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance. Findings included: - The undated Physician Orders, for Resident (R)20 documented diagnoses which included cognitive communication deficit, cerebral vascular accident (stroke is a sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), traumatic…

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 64 residents which included 16 residents sampled, which included two residents reviewed for comprehensive care plan development. Based on interview, observation, and record review, the facility failed to develop a comprehensive, individualized person-centered care plan for Resident (R) 25 related to the use of grab bar use for bed mobility and for R27 to include the use of oxygen and oxygen related equipment. This deficient practice placed the residents at risk for uncommunicated care needs. Findings include: - The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body). R25's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 64 residents with 16 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to use proper hand hygiene and Enhanced Barrier precautions (EBP) when providing urinary catheter care for resident (R)1 and R25. Findings included: - R1's Electronic Medical Record (EMR) revealed diagnoses that included acute kidney failure (a sudden decline in kidney function that occurs within a few hours or days), neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urinary tract infection ([UTI] infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). R1's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident…

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 64 residents with 16 residents sampled, including three residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean and store a nebulizer (a device for administering inhaled medications) for Resident (R)28 and R11 in accordance with the standards of care. In addition, the facility failed to place a date label on the oxygen tubing for R27. This deficient practice placed the residents at risk of respiratory complications that could also have a negative impact on the resident's psychosocial wellbeing. Findings included: - R28's Electronic Health Record (EHR) documented pertinent diagnoses of atherosclerotic (buildup of plaques in the blood vessels) heart disease, history of pulmonary embolism (a blood clot in the blood vessels of the lungs), asthma (a chronic disorder of narrowed airways that caused wheezing and shortness of breath), generalized weakness, difficulty in walking and respiratory failure (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 64 residents which included 16 residents sampled, which included one resident reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to assess Resident (R)25 for safety and risk of entrapment from bed rail use and failed to ensure R25 obtained informed documented consent from the resident or resident representative prior to installation of the siderails. This deficient practice placed R25 at a risk for uninformed decisions related to the risks and benefits associated with the use of side rails and placed the resident at risk due to possible injury due to bed rail use. Findings include: - The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body). R25's Significant Change Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 67 residents, with three residents included in the sample. Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure a safe environment on 11/20/23, when the facility sent cognitively impaired dependent Resident (R)1 to R2's medical appointment. The facility mixed up R2 and R1's identity and dropped off R1 at the front doors of a medical clinic, alone, for R2's appointment. R1 did not have any identification on him and did not know why he was at the appointment. The facility did not know R1 was out of the facility until the medical clinic staff called the facility to point out the facility dropped off the incorrect resident. Finding included: - The Physician Orders for R1, dated 10/18/23, revealed a diagnosis of cognitive communication deficit (difficult recalling short-term or long-term information). The Significant Change of Status Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview Mental Status score of…

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

The facility had a census of 59 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to store, distribute and serve food in accordance with professional standards for food service safety for the 59 residents who resided in the facility and received their food from the facility kitchen and two kitchenettes, when staff failed to use safe food handling, failed to dispose of expired food items, failed to disinfect a thermometer between food items when checking the temperatures of the food, and failed to wear a hair net in the kitchen during the preparation a meal. Findings included: - On 06/21/22 at 08:18 AM, observation revealed the kitchen freezer had the following undated or expired food items: 1/2 bag of French fries 1/4 bag of French fries 1/4 bag of chicken strips 1/4 bag of tater tots On 06/22/22 at 11:10 AM, observation revealed in the kitchen, during the preparation of the noon meal, Dietary Staff (DS) CC without a hair net. On 06/21/22 at 08:10 AM, DS BB verified the items in the kitchen freezer and discarded 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 59 residents. The sample included 18 residents. Based on observation, interview, and record review the facility staff failed to treat Resident (R) 4 and R16 with dignity when staff checked their blood pressure (test measures the pressure in your arteries as your heart pumps) and administered their insulin (a medication used to regulate blood sugar levels) at the dining room table, with nine other residents able to view them during meal service and dining. The staff also failed to close the bedroom curtain to promote dignity and privacy, while R8 sat on a bed pan. Findings included: - On 06/22/22 at 08:10 AM, observation revealed Licensed Nurse (LN) G checked R4's and R16's blood pressure and administered their insulin at the dining room table with nine other residents able to view the procedures. On 06/22/22 at 08:12 AM, LN G stated sometimes she checked R4 and R16's blood pressure and administered their insulin at the dining room table because they wanted her too. On 06/27/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 59 residents. The sample included 18 residents with two reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide the resident or resident representative with written information regarding the facility bed hold policy, when R18 transferred to the hospital. This placed R18 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R18's Electronic Medical Record (EMR) documented the resident had diagnoses of major depressive disorder (major mood disorder), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, and altered mental status (state of awareness that was different from the normal awareness of a person). R18's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS…

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

The facility had a census of 59. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide care in a timely manner for Resident (R) 54 when facility staff did not answer her call light (used to request assistance) for 28 minutes. This deficient practice placed R54 at risk to not have care or assistance in a timely manner. Findings included: - R54's Physician Oder Sheet, dated 06/21/22, included diagnoses of cerebrovascular accident (CVA, stroke, sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), meningitis (infection of meninges, protective tissue of the brain that causes stiff neck, headache and fever), and myopathy (disorders in which the primary symptom is muscle weakness due to dysfunction of muscle fiber). The Care Plan, dated 06/12/22, directed staff to anticipate and meet the resident's needs, ensure her call light remained…

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 59 residents. The sample included 18 residents with two reviewed for pain. Based on observation, interview, and record review the facility failed to provide interventions during wound care to manage Resident (R) 2's distress and pain. This placed the resident at risk for prolonged and unnecessary pain or distress. Findings included: - R2's Physician Order Sheet dated 06/21/22, included diagnoses of anxiety (mental or emotional reaction characterized by apprehension), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hyponatremia (greater than normal concentration of sodium in the blood), and right-side hemiplegia (paralysis of one side of the body). R2's Quarterly Minimum Data Set (MDS) assessment, dated 04/21/22, documented R2 had severely impaired cognition and required extensive assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented the resident had no skin issues, and received scheduled pain medication…

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 59 residents. The sample included 18 residents with one reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review the facility failed to obtain communication from the dialysis center regarding Resident (R) 33's health status with each procedure. This deficient practice placed R33 at risk for unmet needs due to lack of information regarding the resident's health status during the dialysis procedures. Findings included: - R33's Physician Order Sheet (POS), dated 06/21/22, documented diagnoses of end stage renal disease (condition where the kidney reaches advanced state of loss of function), and type 2 diabetes mellitus (condition from insufficient production of insulin, causing high blood sugar). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented the resident was independent with eating,…

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 59 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow up on the Consultant Pharmacist request for an appropriate diagnosis for the use of Seroquel, an antipsychotic (a drug used to treat psychotic disorders) medication for Resident (R) 13. This deficient practice placed R13 at risk for adverse effects related to the use of antipsychotic medication. Findings included: - R13's Physician Order Sheet (POS), dated 06/16/22, documented diagnoses of cerebral infarction (stroke), atherosclerosis (condition where the arteries become narrowed and hardened due to buildup of plaque (fats), dementia (group of symptoms that affects memory, thinking and interferes with daily life), vertigo (sense of spinning experienced even when someone is perfectly still), myoclonus (spasmodic jerky contraction of groups of muscles), hallucinations (experience in which you see, hear, feel, 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 59 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure Resident (R) 13 did not receive antipsychotic (a drug used to treat psychotic disorders) medication without an appropriate diagnosis. This deficient practice placed R13 at risk for adverse effects related to the use of antipsychotic medication. Findings included: - R13's Physician Order Sheet (POS), dated 06/16/22, documented diagnoses of cerebral infarction (stroke), atherosclerosis (condition where the arteries become narrowed and hardened due to buildup of plaque (fats), dementia (group of symptoms that affects memory, thinking and interferes with daily life), vertigo (sense of spinning experienced even when someone is perfectly still), myoclonus (spasmodic jerky contraction of groups of muscles), hallucinations (experience in which you see, hear, feel, or smell something that does not exist), metabolic…

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 59 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide thorough infection control during a wound dressing change for Resident (R) 21 and failed to update their Infection Control policies annually. This deficient practice placed R21 at increased risk for infection. Findings included: - On 06/22/22 at 10:55 AM, observation revealed R21 laid in bed, on his right side. Licensed Nurse (LN) GG placed a clean bed pad under R21's left leg and unwrapped the wound dressing. The gauze wound dressing had a large amount red/yellow drainage, with slough (dead tissue). After LN GG removed the soiled wound dressings and her gloves, she washed her hands and applied new gloves. LN GG set the wound care supplies on the bedside table without first cleaning or disinfecting the table and she did not place a clean towel on the contaminated surface. Observation revealed the same bedside table held a urinal with dark yellow fluid and an empty, used urinal. On 06/22/22 at 11:05 AM, LN GG verified she…

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 59 residents. The sample included 18 residents. Based on observation and interview the facility failed to provide sufficient space in one of two dining areas to accommodate residents' needs. Findings included: - On 06/21/22 at 11:57 AM, observation in the east dining room revealed residents seated at dining room tables, other residents entered the dining room, some with wheelchairs, others with walkers, and staff moved residents away from their tables so other residents entering could get to the tables for the noon meal. On 06/22/22 at 11:30 AM, observation revealed residents seated at the dining room tables. The staff had to move residents currently seated at the dining room tables, away from their tables, so other residents could get to the tables for the noon meal. On 06/27/22 at 02:04 PM, Administrative Nurse D stated she could see how the east dining room was crowded and they needed to try to rearrange the tables to make more room, because not all of the residents on that end come out for dining at this time. On 6/27/22 at 03:31 PM, Administrative…

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.