Great Plains Post Acute

Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to wear appropriate Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) for one resident, Resident (R) 107. Findings included:- On 04/21/26 at 07:45 AM, R107's room had EBP signage at the room entrance. Certified Nurse Aide (CNA) M and CNA O gowned but did not put on a gown. The CNAs removed R107's incontinence brief, and CNA M started to perform personal care to R107. R107 asked them if she needed to hold up her belly for them to wipe. CNA M stated, Yes, and after she held up her belly, CNA M wiped, and R107 said it hurt. R107 had a small open area under her belly. Licensed Nurse (LN) H was informed of the opening and came in, without a gown, and applied a cream to the area and stated she would get an order for treatment…

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.

Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room. Findings included:- On 04/22/26 at 09:49 AM, observation in the laundry room revealed the following:1. Missing floor tile along the front of the two front loader washing machines and behind the washers, approximately five feet (ft) by eight inches (in). 2. Behind the washing machines were two floor grates, approximately two ft by 18 in with grayish-black fuzzy substance on the top of them.3. The right front loader washing machine had numerous different-sized streaks of dried white substance below the door and on the right side.4. Underneath the sink, located in the clean area, had missing tile approximately two ft by 18 in. On 04/22/27 at 09:49 AM, Laundry Supervisor (LS) U verified the above findings and stated maintenance was responsible for cleaning the area, and the tile was supposed to be replaced a year ago. On 04/22/26 at 11:17 AM, Maintenance Supervisor (MS) V verified the above findings and stated he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 105 residents with four residents included in the sample. Based on interview and record review the facility failed to ensure the staff administration of resident's medication met professional standards. The Certified Medication Aide administered Trazodone to Resident (R)2 at the incorrect time, and left R3's medication in her room, without observing the resident consume the medication and staff later found 15 medication cups with one gabapentin (medication used for nerve pain) and one tramadol (medication used for moderate to severe pain) in each cup and also found 19 tramadol pills in R3's drawer. Findings included: - R2's Electronic Medical Record (EMR) dated 05/29/24 indicated the following diagnoses: acute/chronic respiratory failure with hypoxia (persisting for a long period, often for the remainder of a person's lifetime, chronically poor airflow) and type two diabetes (a disease in which the body's ability to produce or respond to the hormone insulins is 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.

The facility identified a census of 102 residents, which included 57 residents with active trusts held by the facility. Based on observations, interviews, and record review, the facility failed to provide quarterly statements for the 57 residents with trust accounts in the facility. Findings included: - Review of Trust Transaction History of all 57 residents who had active trusts held by the facility revealed no quarterly statements available for review. During an interview on 02/11/25 at 10:19 AM Administrative Staff PP revealed the facility maintained trust funds for 57 residents in the facility. Administrative Staff PP revealed quarterly statements were printed out and hand delivered to residents that had high cognitive functioning or mailed to the residents' representatives if the resident had low cognitive functioning. The facility was unable to provide documentation, which indicated quarterly statements were given to the 57 residents of the facility. The facility did not provide a policy related to management of trust funds. The facility failed to provide quarterly statements…

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 102 with 21 residents in the sample. Based on observations, interview and record review the facility failed to ensure competent nursing staff when the LN did not apply a pressure dressing to R5's ruptured and heavily bleeding hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the resident's right lower leg. The facility failed to maintain the quality of care for R409 which included lack of assessment, documentation from a fall on 01/27/25 which caused a fracture (broken bone) of the pelvic area. Findings included: - The Physician's Orders dated 02/03/25 revealed R5 had a diagnosis of hemiplegia (muscle weakness of one half of the body) and hemiparesis (paralysis of one side of the body) following a cerebral infraction (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). The Significant Change Minimum Data Set (MDS) dated…

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

The facility reported a census of 102 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for five of the five direct care staff reviewed, to ensure the residents receive adequate cares. Findings included: - Review of employment files for five sampled certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for one year or more revealed all five lacked an annual performance review for: 1. CNA VV 2. CNA WW 3. CMA XX 4. CMA YY 5. CNA ZZ On 02/10/25 at 11:13 AM Administrative Staff A confirmed the five direct care/CMA/CNA reviewed lacked annual performance evaluations. She stated that the direct care staff employed over one year should have an annual performance review which included identified weaknesses and action plan to improve their performance. The nursing staff work throughout the facility with all the residents. The facility failed to provide a policy to address completion of a required performance review to identify direct care staff weaknesses and an action plan to improve staff…

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

The facility reported a census of 102 residents with 21 residents sampled for review. Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from the resident's bedside, toilet, and bathing facilities. Findings included: - Tour on 02/03/25 at 02:30 PM, of the facility revealed call lights from any resident room or bathing facility area in the facility had only a light above the door that activated upon the call light being activated. When the call light was activated, the only indicator was the light above the door in the hallway that had no audible indicator nor to a console anywhere else in the facility. Review of the November 2024 through February 2025 resident council minutes, including grievances, documented the council reported the following: On 11/08/24 residents reported that call lights were not answered timely, with no response noted. On 12/13/24 residents reported…

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 102 residents. Based on observation, interview, and record review, the facility failed to ensure the continuing competence of nurse aides included annual mandatory training for abuse, neglect, and exploitation training. Findings included: - Review of employment files for five sampled certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for one year or more revealed all five lacked continuing education, training provided for Abuse, Neglect, and Exploitation (ANE) for: 1. CNA VV 2. CNA WW 3. CMA XX 4. CMA YY 5. CNA ZZ On 02/10/25 at 11:13 AM, Administrative Staff A, confirmed the . above findings. She stated the facility should ensure the staff employed over one year should continuing education which include the mandatory Inservice training to for Abuse Neglect and exploitation (ANE). Additionally, she reported she could not guarantee the above noted staff had received mandatory in-services for ANE. The facility policy Abuse Prevention Program, dated 04/2021, documentation include the facility should provide staff…

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

The facility reported a census of 102 residents. Based on observation, interview, and record review, the facility failed to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and Include dementia management training and resident abuse prevention training and address areas of weakness as determined in nurse aides' performance reviews which address the special needs of residents as determined by the facility staff. Findings included: - Review of employment files for five sampled certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for one year or more revealed all five lacked 12 hours of continuing education, training provided based on identified weaknesses, or evidence of mandatory training which included Abuse, Neglect, and Exploitation for: 1. CNA VV 2. CNA WW 3. CMA XX 4. CMA YY 5. CNA ZZ On 02/10/25 at 11:13 AM, Administrative Staff A, confirmed the . above findings. She stated the facility should ensure the staff employed over one year should have a minimum of 12 hours of continuing education which include…

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 102 residents. The sample included 21 residents with seven residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to seven residents, Resident (R) 14, R75, R79, R88, R92, R96, and R409 and/or their representative with a written notice specifying the duration of the bed-hold policy, at the time of the residents' transfers to the hospital. Findings include: - Review of R14's Electronic Health Record (EHR) revealed the lack of a completed bed hold form, or a progress note of a bed hold obtained, when R14 admitted to the hospital on [DATE] and 01/11/25. Review of R75's EHR revealed the lack of a completed bed hold form, or a progress note of a bed hold obtained, when R75 admitted to the hospital on [DATE]. Review of R79's EHR revealed the lack of a completed bed hold form, or a progress note of a bed hold obtained, when R79 admitted to the hospital on [DATE], and 11/12/24. Review of R88's EHR revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Review of the Resident (R)82's, Physician Orders, dated 05/18/22, revealed diagnoses which included anxiety disorder, muscle weakness, reduced mobility, obesity (severe overweight), and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documentation included her Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She reported it was very important to choose what clothes to wear and type of bath. The resident was dependent on staff for partial to moderate for assistance with bathing and dressing. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/06/25 documentation included the resident remained in the facility for assistance with cares. Resident has diagnosis included heart failure, major depressive disorder, respiratory failure, chronic kidney diseases, morbid obesity, chronic obstructive pulmonary disease (COPD-), and hypertension (high blood pressure). The resident was incontinent of bladder and…

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

The facility reported a census of 102 residents which included 21 residents sampled and seven reviewed for ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) care. Based on observations, interviews and record reviews, the facility failed to provide baths and/or showers to six residents who were dependent on staff for ADL care, Resident (R) 27, R80, R79, R76, R88 and R82. These deficient practices led to a failure to ensure the necessary services required for good personal hygiene were provided to the residents in the facility. Findings included: - Review of Resident (R) 79's Electronic Health Record (EHR) bathing task list from 01/06/25 to 02/02/25 revealed the resident received bath on 01/06/25 and 02/02/25. Review of R80's EHR Bathing Task List from 01/05/25 to 02/03/25 revealed the resident received baths on 01/06/25, 01/09/25, 01/11/25, 01/12/25, 01/28/25 and 02/01/25 with a documented refusal of a bath on 02/02/25. Review of R27's EHR Bathing Task List from 01/05/25 to 02/03/25 revealed the resident received baths 01/06/25, 01/09/25 and…

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

The facility had a census of 102 residents. The sample included 21 residents. Based on observation, interview, and record review, the facility failed to serve the residents of the facility food, which was palatable, attractive, and served at the appropriate temperature. Findings included: - During an interview on 01/30/25 at 12:48 PM, Resident (R) 92 reported food does not always taste good and is served cold. During an interview on 02/03/25 at 09:09 AM, R85 reported he felt like the kitchen staff do not care, the food is cold and does not taste well at times. During an observation on 02/04/25 the prepared food was placed on the steam table at 10:30 AM and had reached correct cooked temperatures. The pureed corn temperature read at 105 degrees Fahrenheit (F). These food items were below the required serving temperature of 135 degrees F. Dietary Staff CC used the same thermometer to complete temperatures on all the food. She used a white cloth towel that she picked up from the counter and wiped off the thermometer after each food item temperature was obtained with the same white…

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 102 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - Observation of the kitchen and food storage areas on 01/30/25 at 11:15 AM, revealed the following areas of concern: A large bag of panko crumbs with a ripped hole in the center of the bag, not sealed properly. There was a piece of plastic wrap laid partially over the ripped hole, no date when bag was opened. Several bags of pasta were opened and not sealed. A bag of honey granola no date labeled when opened. Two standing freezers in dry storage area had several unidentifiable frozen items in the door no dates and no labels noted. Turkey burgers no expiration date and no label. On the top shelf of standing freezer was a bag of cut up potatoes and some kind of pink meat that had no label or date. Dietary Staff BB (Dietary Manager) reported that the bag of potatoes and turkey that was noted was just used and should have…

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 102 residents with 21 residents sampled. Based on interview, observation, and record review the facility failed to protect the dignity of Resident (R) 80 and R27 when the staff failed to remove unwanted facial hair and/or trim resident fingernails as needed. The facility further failed to ensure staff knocked before entering resident rooms and blinds were closed to the outside when performing resident care activities. These practices had the potential to lead to negative psychosocial effects related to dignity. Findings included: - An observation on 01/30/25 at 01:14 PM, R80 sat in his wheelchair with visitor present and visible facial hair over one inch long present on R80's face. During the obsesrvation an unknown staff member walked into R80's room without knocking or announcing themself. When the staff member was greeted by R80, the staff member turned around and walked out of the room. During an interview on 01/30/25 at 01:14 PM, R80 revealed he preferred to be clean shaven and stated staff had not assisted him. R80 stated the presence of his…

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 102 residents with 21sampled, which included three residents reviewed for choices. Based on observation, interview, and record review, the facility failed to provide choices for dependent Resident (R) 82 related to her preferences for type and frequency of bath/shower. Findings included: - Review of the Resident (R)82's, Physician Orders, dated 05/18/22, revealed diagnoses which included anxiety disorder, muscle weakness, reduced mobility, obesity (severe overweight), and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documentation included her Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. She reported it was very important to choose what clothes to wear and type of bath. The resident was partial to moderate dependent on staff for assistance with bathing and dressing. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/06/25 documentation included 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.

The facility reported a census of 102 residents. The sample included 21 residents. Based on interview and record review the facility failed to ensure the correct and complete Beneficiary Protection Notification Forms were issued to one of three residents reviewed, Resident (R)56. Findings included: - On 02/10/25 review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055 (SNF ABN) revealed Resident (R) 56 lacked the SNFABN form. On 02/11/25 at 10:49 AM, Administrative Staff A confirmed the form should have been given as required. The facility's policy Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated September 2024, documented residents were given a Skilled Nursing Facility Advance Beneficiary Notice (CMA form 10055) when termination- if the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered, the SNF ABN is issued to the beneficiary before such extended care items or services…

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 102 residents. The sample included 21 residents with eight reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide written notice for facility-initiated transfers for Residents (R) 79 or their representative when they were transferred to the hospital. Findings included: - Review of the Electronic Health Record (EHR) census log for R79 revealed a discharge from the facility to a hospital on [DATE] and noted the resident readmitted to the facility on [DATE]. Additionally, a discharge from the facility to a hospital on [DATE] and noted the resident readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative related to this discharge/transfer. During an interview on 02/11/25 at 08:25 AM Social Services Designee (SSD) X revealed when a resident was sent to the hospital, the nursing staff would notify the resident and/or resident's representative…

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 census totaled 102, with 21 residents in the sample. Based on observation, interview, and record review the facility failed to provide the necessary care for Resident (R) 88 related to obtaining ordered medications. Findings included: - Resident (R) 88's Electronic Health Record (EHR) revealed diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), pain, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated 01/01/25, documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment documented R88 was continent of bowel and occasionally incontinent of bladder and required substantial/maximal assistance with ADL's (activities of daily living such as grooming, shower, footwear). The Electronic Health Record (EHR) documented an order dated 12/09/24 for Replens external comfort vaginal gel (vaginal…

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 102 residents, with 21 sampled, one resident was reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients though a tube) management. Based on observation, interview, and record review, the facility failed to check for residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) or placement prior to a bolus feed (a method of administering liquid nutrition through a feeding tube). Additionally, staff failed to have head of bed elevated for at least 60 minutes after a bolus feed was completed. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R14's diagnoses from the Electronic Health Record (EHR) documented, anorexia (lack or loss of appetite), metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (progressive mental disorder characterized by failing memory, confusion).…

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 102 residents with 21 residents sampled, including one resident reviewed for dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney). Based on observation, record review, and interview the facility failed to ensure coordination of care between the dialysis center and the facility, for one Resident (R) 85, regarding a lack of regular dialysis communication sheets, with the facility. Findings included: - Review of R85's Electronic Health Record (EHR), revealed a diagnosis of end stage renal disease (ESRD a condition in which the kidneys do not function normally and requires external support to meet the daily requirements of life). The 08/19/24 Annual Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received dialysis while a resident of the facility. No weight loss or gain concerns noted. The 08/23/24 Dehydration/Hydration Care Area Assessment (CAA) documented R85 was on dialysis due to ESRD. Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 98 residents. The sample included three residents reviewed for misappropriation of property. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from misappropriation of medications when two tablets of Percocet (narcotic pain medication) were unaccounted for and never found by the facility. This deficient practice had the risk of missed medications and further misappropriation of medications for R1. Findings included: - R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and primary generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS) dated 05/15/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R1 received scheduled pain medications and complained of occasional pain rated highest at eight out…

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 98 residents. The sample included three residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to implement interventions to prevent falls for Resident (R) 2, who was at risk for falls. This deficient practice had the risk of further falls/injuries and unwarranted physical complications for R2. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left non-dominant side, abnormal posture, generalized muscle weakness, and dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Annual Minimum Data Set (MDS) dated 11/22/23, documented R2 had a Brief Interview…

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 104 residents. The sample include 23 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Findings Included: - An inspection of the facility revealed grievance form available in the front lobby on a table. The inspection revealed the facility had no labeled grievance boxes or other visible method in place to submit the form anonymously. On 06/27/23 at 01:30PM in a confidential interview, Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported they turned their complaints into Social Services X. The council residents stated they were not aware of any grievance form drop box or system the facility had in place. On 06/28/23 at 12:20PM Social Services X reported the residents could put anonymous grievances in his mailbox outside his door. He…

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

- The facility identified a census of 104 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene during cares, disinfecting of shared equipment, monitoring of washing machine water temperature logs, and proper care for catheter (tube inserted into the bladder). The facility failed to ensure staff wore proper personal protective equipment (PPE) when care was provided for residents on enhanced barrier precautions. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 06/26/23 at 07:36 AM review of the washing machine water temperature logs from 03/01/23 to 06/26/23 (118 days) revealed laundry water temperatures were assessed and documented on the following dates: 03/24/23, 04/14/23, 04/21/23, 05/12/23, 05/19/23, 06/05/23, and 06/16/23. On 06/26/23 at 03:40PM Resident (R)88's urinary catheter collection bag sat on the floor next to his bed without a barrier to protect from contamination. On 06/28/23 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.

The facility identified a census of 104 residents. The sample included 23 residents. Based on observation, and interviews, the facility failed to provide a clean, home-like environment for all the residents who resided in the facility. This placed the affected residents at risk for impaired health and wellness. Findings included: - On 06/26/23 at 07:18 AM the north hallway had a strong urine odor. An unused oxygen concentrator sat in the hallway. On 06/26/23 at 07:30 AM the south hallway had empty armchairs lining the wall on one side of the hallway. Nursing staff stood on the other side of the hallway with medication carts. Residents had difficulty propelling their wheelchairs down the hallway. On 06/27/23 at 01:25 PM R20's window curtain-panel was discolored grey, torn, and pinned up to prevent the curtain from blocking the air flow from the heater/air conditioning system under the window. Wallpaper peeled away from the wall beside the heating/air conditioning device and behind the headboard of the bed. On 06/29/23 at 09:20 AM R38's room wallpaper peeled away from the wall. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 104 residents. The sample included 23 residents with three residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to ensure Resident (R) 88's urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag was placed in a privacy bag and a privacy curtain was provided during personal care. This deficient practice placed R88 at risk for impaired dignity and decreased psychosocial well-being. Findings included: - R88's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented that R88 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 had a census of 104 residents. The sample included 23 residents with two reviewed for accommodation of needs. Based on observation, record review and interview the facility failed to provide foot pedals for Resident (R)19's wheelchair. This placed the resident at risk for preventable accidents due to lack of necessary equipment. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of seizures (violent involuntary series of contractions of a group of muscles), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder), muscle weakness, morbid obesity (severely overweight). R19's Quarterly Minimum Data Set (MDS) completed 03/21/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required extensive assistance from two staff for bed mobility, transfers, locomotion,…

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 104 residents. The sample included 23 residents with three residents reviewed for beneficiary notices review. Based on observation, record review, and interviews, the facility failed to provide Resident (R)307, who had Medicare Part A days remaining, with an Notice of Medicare Non-coverage (NOMNC CMS-form 10123) as required. This deficient practice placed R307 at risk for uninformed decisions and impaired ability to appeal. Findings Included: - A review of R307's Discharge Minimum Data Set (MDS) completed 04/06/23 indicated she had a Brief interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she had a planned discharge with no return anticipated. The MDS indicated she discharged to the community on 04/06/23. Review of R307's Electronic Medical Record indicated that her last covered day (LCD) for Medicare Part A services was 04/06/23. R307 was discharged from the facility on 04/06/23. The facilty was unable to provide evidence R307 received a NOMNC. On 06/28/23 an review of R307 Beneficiary Notification…

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 104 residents. The sample included 23 residents. Based on observation, record review and interview that facility failed to ensure the residents were free from neglect when the facility failed to provide the necessary care and services for Resident (R) 90 and R19. This deficient practice placed the residents at risk for impaired health and decreased quality of life. Findings included: - The electronic medical record (EMR) for R90 documented diagnoses of schizoaffective disorder (a combination disorder with mood and psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), autistic disorder (a developmental disorder caused by differences in the brain), and cerebral ataxia (impaired ability to coordinate muscle movement). The admission Minimum Data Set (MDS) dated [DATE] for R90 documented R90 had both long and short -term memory problems. R90 had severely impaired cognitive skills for daily decision…

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 104 residents. The sample included 23 residents with four residents reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to identify as an allegation of abuse, and report to the appropriate abuse coordinator within the facility, when Resident (R)3 reported rough handling during cares to nursing staff. This placed R3 at risk for unidentified and ongoing abuse and /or neglect and related complications. Finding included: - The Medical Diagnosis section within R3's Electronic Medical Records (EMR) included diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), morbid obesity (severely overweight), reduced mobility, unsteadiness on feet, muscle weakness, heart failure (severe failure of the heart to function properly), and rotator cuff tear (right shoulder tear). A review of R3's admission Minimum Data Set (MDS) dated 05/18/23 noted Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 104 residents. The sample included 23 with two reviewed for transfer notifications. Based on record review, observations, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer to the hospital for Resident (R)91 or her representative. This deficient practice placed R91 at risk of delayed care or uninformed choices. Findings Included: - The Medical Diagnosis section within R91's Electronic Medical Records (EMR) included diagnoses of chronic respiratory failure, hearing loss, muscle weakness, peripheral vascular disease (PVD-circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), urinary retention, acute kidney failure, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and end stage renal disease. R91's Discharge Minimum Data Set (MDS) completed 03/27/23 noted a Brief Interview for Mental Status…

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

The facility identified a census of 104. The sample included 23 residents with 23 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to complete care plan revisions for Residents (R)89. This deficient practice placed the residents at risk for ineffective treatment and unmet care needs. Findings Included: -The Medical Diagnosis section within R89's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anoxic brain damage (brain damage caused by lack of oxygen), need for assistance with personal cares, traumatic brain injury, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), aphasia (condition with disordered or absent language function), and dysphagia (swallowing difficulty). A review of R89's Quarterly Minimum Data Set (MDS) dated 04/14/23 noted a Brief Interview for Mental Status (BIMS) score could not be completed due to severe cognitive…

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 104 residents. The sample included 23 residents with one resident reviewed for communication. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)70 received the necessary services to promote meaningful interaction and communication to support both physical and psychosocial needs in the presence of a language barrier. This deficient practice placed R70 at risk for unidentified care needs as well as risk for isolation and/or loneliness. Findings included: - The Diagnoses tab of R70's Electronic Medical Record (EMR) revealed diagnoses for end stage renal disease, dependence on renal dialysis (procedure where impurities or wastes were removed from the blood), dementia (progressive mental disorder characterized by failing memory, confusion), and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought]). The Annual…

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 104 residents. The sample included 23 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for Resident (R) 38 who required assistance from staff to complete the care. This deficient practice placed resident R38 at risk for further potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R38's Electronic Medical Record (EMR) from the Diagnoses tab documented 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), and 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) affecting left non-dominant side. The Annual…

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 104 residents. The sample included 23 residents with four residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure Resident (R)19 had a safe/functionable shower chair to prevent avoidable accidents. This deficient practice placed the resident at risk for preventable accidents and injuries. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of seizures (violent involuntary series of contractions of a group of muscles), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder), muscle weakness, morbid obesity (severely overweight). R19's Quarterly Minimum Data Set (MDS) completed 03/21/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment.…

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 104 residents. The sample included 23 residents with six residents reviewed for bowel/bladder incontinence, catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 88 and R83 with indwelling catheters when the facility failed to prevent the catheter drainage bag from resting on the floor and the facility failed to maintain the catheter drainage bag below R88's bladder. The facility also failed to have an appropriate indication for R88's catheter and have an anchor for the catheter tubing to prevent pulling a d injury. This deficient practice placed these residents at risk for catheter related complications. Findings included: - R88's electronic medical record (EMR) from the Diagnoses tab documented…

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 104 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis (procedure where impurities or wastes were removed from the blood) facility regarding dialysis care and services and failed to obtain physician ordered weight for Resident (R) 305, who was on a fluid restriction and received dialysis. This deficient practice placed R305 at risk of physical complications related to dialysis. Findings included: - The Electronic Medical Record (EMR) documented R305 had diagnoses of end stage renal disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), chronic pain syndrome, acute pain due to trauma, muscle weakness, fracture (broken bone) of second lumbar (lower back) vertebra (small bones forming the backbone), and altered mental status. The admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 104 residents. The sample included 23 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of pulse monitoring prior to the administration of a beta blocker (a medication used to slow down the action of the heart), for Resident (R)95. The facility failed to ensure the CP identified and reported an inappropriate indication for R93's antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (antipsychotic) and R13's Vrylar (antipsychotic). The facility failed to ensure the CP identified and reported R13's blood glucose (the amount of sugar in the blood) levels that were outside of physician ordered parameters. This failure had to potential of unnecessary medication administration and related side effects for R95, R93, and R13. Findings included: -The electronic…

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 - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), 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), major depressive disorder (major mood disorder), and constipation (difficulty passing stools). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R13 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R13 had received insulin (medication to regulate blood sugar), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), anticoagulant (class of medications used to prevent 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 identified a census of 104 residents. The sample included 23 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure Resident (R) 93's antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel and R13's antipsychotic Vrylar had an appropriate indication for use or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits. This failure had the potential of unnecessary antipsychotic medication use and related side effects for R93 and R13. Findings included: - The electronic medical record (EMR) for R93 documented diagnoses of anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), major depressive disorder (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 identified a census of 104 residents. The sample included 23 residents with three reviewed for physician lab result notification. Based on observation, record review, and interviews, the facility failed to notify the medical provider of Resident (R)21's abnormal digoxin (medication used to treat heart failure and irregular heartbeats) lab result. This deficient practice placed R21 at risk for delayed treatment and/or toxicity. Findings included: - The Medical Diagnosis section within R21's Electronic Medical Records (EMR) included diagnoses of atrial fibrillation (rapid, irregular heartbeat), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), chronic respiratory failure, and heart failure. R21's Quarterly Minimum Data Set (MDS) dated 05/07/23 noted a Brief Interview for Mental Status (BIMS) score could not be completed due to severe cognitive impairment. The MDS indicated she took diuretics (medication to…

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

The facility identified a census of 104 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory test results for Resident (R) 13 and R21 were included in the residents' clinical medical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R13's Electronic Medical Record (EMR) lacked laboratory tests obtained on 04/17/23, 04/25/23, 05/09/23 and 06/21/23. Review of the EMR under Orders tab revealed physician order: Losartan potassium tablet 50 milligram (mg) give one tablet by mouth daily for hypertension (elevated blood pressure). Hold medication until creatine level (kidney function test) returns to baseline, then resume medication dated 04/11/23. On 06/27/23 at 09:24 AM R13 sat on electric wheelchair on the outside patio to smoke. On 06/29/23 at 04:03 PM Administrative Nurse D stated she expected the laboratory tests to be called to the physician upon results arrival and scanned into the medical record within the next day. 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.