Lakepoint Wichita, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 79 residents. The sample included 20 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment and develop a trauma-informed plan of care for Resident (R) 52 and R71, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the residents at risk for unmet behavioral and mental health needs. Findings included: - The Electronic Medical Record (EMR) for R52 documented diagnoses of PTSD, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe…

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 Electronic Medical Record (EMR) for R31 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteomyelitis (local or generalized infection of the bone and bone marrow), pain, atrial fibrillation (rapid, irregular heartbeat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition and was dependent upon staff for transfers. R31 required substantial assistance with toileting, showers, dressing, and mobility, and was independent with transfers. The MDS further documented R31 received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), and hypoglycemic (less than normal amount of sugar in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 88 residents, with three residents in the sample and reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment for one resident by the failure to implement interventions to prevent repeated falls with major injury for Resident (R) 2, who had a fall that resulted in a fractured wrist. Findings included: - R2's Physician orders revealed the following diagnoses included chronic respiratory failure, alcoholic cirrhosis of liver (chronic degenerative disease of the liver) with ascites (abnormal fluid buildup in the abdominal cavity), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R2's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The resident had no…

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 60 residents with four residents selected for review for activity of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure bathing opportunities as per resident preference for three residents (R) 1, R2, and R3 of the four residents reviewed for activities of daily living. Findings included: - Review of Resident (R)1's Physician Order Sheet, dated 09/02/23, revealed diagnoses included cerebral vascular 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), hemiplegia (paralysis of one side of the body muscular weakness of one half of the body), pain, and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident had modified independence in decision making with some difficulty in new situations. The resident was dependent on staff for transfer and dressing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 60 residents with five residents selected for review, which included three residents reviewed for unnecessary medication administration. Based on observation, interview, and record review, the facility failed to administer one resident's (R)3 Percocet (narcotic pain medication), and Metformin (a medication used to lower blood sugar), cyclobenzaprine (a muscle relaxer), doxycycline and cefdinir (antibiotics) as ordered by the physician. Findings included: - Review of Resident (R) 3's Physician Order Sheet, dated 09/11/23, revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), chronic pain syndrome, spinal stroke (blood clot in the spine) and diabetes (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], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal 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 58 residents. Based on record review, and interviews, the facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed specialized training in infection prevention and control. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections. Findings included: - On 03/06/23 the facility identified Administrative Nurse D as the designated IP. On 03/09/23 at 01:05 PM Administrative Nurse D stated the facility did not have a certified Infection Preventionist at this time. Administrative Nurse D stated the facility was in the process of correcting the situation. The facility was unable to provide a policy related to the Infection Preventionist. The facility failed to ensure a staff person was a staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in…

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 48 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure Residents (R)7, R9, R35, and R42 received care in a dignified manner during meal service. The facility additionally failed to ensure R30, R48, and R50 received assistive cares in a dignified manner during basic cares and interactions. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 03/06/23 at 12:02AM R32 (a totally dependent severely cognitively impaired resident) was in the dining room waiting for breakfast. R32 was making cooing sounds and chewing on her blanket. Staff abruptly stated, stop being silly to R32 and pulled the blanket away from her mouth. R32 did not have her doll with her. At 12:45AM R32's food arrived. An unidentified direct care staff came over to the table and loudly stated, I'll feed her and sat next to her. On 03/06/23 at 12:10PM R7 sat in the dining room and waited for her lunch. R7's supplemental oxygen tank was low. 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 identified a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to maintain a homelike environment. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 03/06/23 at 07:00AM an inspection of the facility's kitchen and dining service was completed. Observation of the breakfast and lunch service on 03/06/23 and for both breakfast and lunch for the duration of the survey revealed the residents received their room trays served in Styrofoam plate (boxes) with plastic silverware and disposable cups. On 03/08/23 at 10:51AM Dietary Staff BB stated the facility currently did not have a insulated food delivery cart to keep the trays warm so the kitchen used the Styrofoam plates for residents eating in their rooms. On 03/08//23 at 11:11AM in an interview with Dietary Staff CC reported the facility was still using Styrofoam boxes due to COVID-19 (highly contagious, potentially life-threatening respiratory virus). A review of the facility's…

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 58 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the residents at risk for complications related to decreased psychosocial wellbeing. Findings Included: - On 03/07/23 at 02:30PM Activities Staff Z provided staff-led Bingo for the residents in the 900 hallway recreation room. A review of the facility's Activities Calendar for February 2023 indicated for the weekend dates of the 4th, 5th, 26th revealed no activities provided to the residents. A review of the calendars for January, February, and March of 2023 revealed the facility heavily scheduled television related activities on the weekend. On 03/07/23 at 03:20PM Resident Council members reported that the facility does not provide activities for residents every weekend. The council reported that sometimes they would provide certain events on special occasions, but the activities were not consistently provided. They stated that Activities Staff Z was doing the best he can but could not be…

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 58 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional to ensure supervision of activities, delegation of activities to weekend staff and monitoring of the activities program to ensure it met the needs of the residents. This deficient practice placed the residents at risk for complications related to decreased psychosocial wellbeing. Findings Included: - On 03/07/23 at 02:30PM Activities Staff Z provided staff-led Bingo for the residents in the 900 hallway recreation room. A review of the facility's Activities Calendar for February 2023 indicated for the weekend dates of the 4th, 5th, and 26th revealed no activities provided to the residents. A review of the calendars for January, February, and March of 2023 revealed the facility relied heavily on scheduled television related activities on the weekend. On 03/07/23 at 03:20PM Resident Council members reported that the facility does not provide activities for residents every weekend. The council reported that sometimes they…

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 58 residents and two medication rooms. Based on observation, record review, and interview, the facility failed to properly date and/or discard two individual opened vials of tuberculin (a sterile protein used in a test by injection for infection with or immunity to tuberculosis [TB-a bacterial infection of the lungs]). This deficient practice left the residents being administered the tuberculin at risk for adverse effects or less effective TB screening. Findings included: - On 03/09/23 at 07:59 AM inspection of the 100-hall medication room revealed two individual tuberculin vials which had been opened and accessed and but lacked an open date. According to the Centers for Disease Control and Prevention (CDC) recommendations a tuberculin vial should not be used after opened beyond the use date of 30 days. On 03/09/23 at 08:00 AM Licensed Nurse G stated the vials of tuberculin should have been dated when they were opened. LN G believed once opened the vial were only good for 30 days. On 03/09/23 at 10:31 AM Administrative Nurse D stated she expected…

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 58 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food handling and storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns Findings Included: - On 03/06/23 at 07:00AM an initial walk-through of the kitchen was completed. The walk-through revealed the spice rack storage area was dusty from the used spice containers. On 03/06/23 at 11:50AM staff were in the dining room preparing to serve lunch to the residents. The ice machine's scoop was left in the ice bin in the service area. On 03/07/23 at 07:30AM three Styrofoam food trays sat on top of the food service station. The containers remained at the service station unheated until Dietary Staff EE loaded them onto a delivery cart to be sent to the residents' rooms at 07:44AM. The Styrofoam trays contained eggs and bacon for Resident(s)11 and R211. A third unlabeled tray was present with eggs and bacon. The trays for R11 and R211 were…

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 58 residents. Based on observation, and interviews, the facility failed to maintain adequate infection control practices when staff failed to store oxygen tubing in a sanitary manner and failed to disinfect a shared glucometer (device used to measure blood glucose levels) after use. The facility further failed to ensure sharps (needles devices to break the skin) were disposed of in a safe, sanitary manner to prevent infections related to needle stick accidents. This deficient practice placed the affected residents at increased risk for the spread of pathogens and infections. Findings included: - On 03/06/23 at 02:55 PM observation in the 100 hallway revealed a wheelchair sat in the hall. The chair had a portable oxygen canister hanging on the back of the chair with an unbagged nasal cannula (tube to provide oxygen through the nose) connected to the canister and lying in the seat of the wheelchair. A storage bag hung from the back of the wheelchair. On 03/07/23 at 07:36 AM…

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 58 residents. The sample included 15 residents with five reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination and pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations or administration information for Resident (R) 38, R32, R45 and R26. This placed the residents at increased risk for influenza, pneumonia, and related complications. Findings included: - Review of R38's clinical record lacked documentation the influenza and pneumococcal vaccine was offered or declined. Review of R32's clinical record lacked documentation the pneumococcal vaccine was offered or declined. Review of R45's clinical record lacked documentation the influenza and pneumococcal vaccine was offered or declined. Review of R26's clinical record lacked documentation the pneumococcal vaccine was offered or…

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

The facility identified a census of 58 residents with 15 residents included in the sample. The facility identified eleven residents who discharged from Medicare Part A services . Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) and Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 which contained the required information and within the required timeframes for Resident (R) 24 and R261. This failure placed the residents at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R24's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 12/08/22 and ended on 12/19/22. R24 remained in the facility for custodial care. The facility did not issue the SNF ABN…

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 58 residents. The sample included 15 residents with three residents sampled for hospitalization/transfer. Based on observation, record review, and interview, the facility failed to provide written notice of transfer with the required information to Resident (R) 3 and R38 or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R3 and R38. Findings included: - The electronic medical record (EMR) for R3 documented diagnoses of urinary tract infection (UTI-an infection in any part of the urinary system), sepsis (a life-threatening medical emergency due to the body's extreme response to an infection), multiple sclerosis (MS-a progressive disease of the nerve fibers of the brain and spinal cord). 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 58 residents. The sample include 15 residents. Based on record review, observations, and interviews, the facility failed to transmit Resident (R) 41's discharge Minimum Data Set (MDS) within the required timeframe. Findings Included: - The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of coronary artery disease (abnormal condition that may affect the flow of oxygen to the heart), hypertension (high blood pressure), hepatitis (inflammatory condition of the liver), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), lung cancer, and respiratory failure. A review of R41's EMR revealed he admitted to the facility on [DATE] and passed away at the facility on 11/06/22. R41's admission MDS dated 10/14/22 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS indicated he was on Hospice Services (end of life services that provide…

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 58. The sample included 15 with 15 residents review for care plan revision. Based on observation, record review, and interviews, the facility failed to revise the fall care plan with interventions for Resident (R) 10. The facility further failed to revise the plan of care with dementia (progressive mental disorder characterized by failing memory, confusion) related interventions for R9, R32, and R18. This deficient practice placed both residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing due to uncommunicated care needs. Findings included: -The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 58 residents. The sample included 15 residents with seven residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 18 was assisted with his hearing aids. This deficient practice placed R18 at risk of difficulty with communication, possible isolation and decline in cognition. Findings included: - R18's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, atrial fibrillation (rapid, irregular heartbeat), 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), and hypertension (elevated blood pressure). 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…

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 58 residents. The sample included 15 residents with seven residents reviewed for activities of daily living (ADLs) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for two residents who required assistance from staff to complete the care. This deficient practice placed resident (R)18 and R15 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, atrial fibrillation (rapid, irregular heartbeat), 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), and hypertension (elevated blood pressure). The admission Minimum Data Set…

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 58 residents. The sample included 15 residents with five residents sampled for positioning. Based on observation, record review, and interview, the facility failed to ensure staff consistently provided care to R14 to help maintain bed mobility/positioning, and assistance with eating. This placed R14 at increased risk for a decline in range of motion and decreased independance. Findings included: - The electronic medical record (EMR) for R14 documented diagnoses of hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), abnormal posture (rigid body movements and chronic abnormal positions of the body), and contracture of the lower leg muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). The Annual Minimum Data Set (MDS) dated 04/20/22 documented R14 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 58 residents. The sample included 15 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide consistent dementia care and services for Residents (R)9 and R32. This deficient practice placed both residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing. Findings included: -The Medical Diagnosis section within R9's Electronic Medical Records (EMR) included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormal posture, 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), chronic obstructive pulmonary disorder (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in…

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 58 residents. The sample included 15 residents with five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for physician ordered antihypertensive (class of medication used to treat high blood pressure) medication was administered outside physician ordered parameters for Resident (R) 18 and R26. This placed the affected residents at risk for unnecessary medication and possible side effects or complications. Findings included: - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, atrial fibrillation (rapid, irregular heartbeat), 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), angina (chest pain), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, atrial fibrillation (rapid, irregular heartbeat), 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), angina (chest pain), and hypertension (elevated blood pressure). 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 R18 required limited assistance of one staff member for ADLs. The MDS documented R18 required physical assistance with bathing with no set assistance during the look back period. The Quarterly MDS dated 12/15/22 documented a BIMS score of zero which indicated a severely impaired cognition. The MDS documented that R18 required extensive assistance of one staff member for ADLs. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 58 residents. The sample included 15 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the physician documented an appropriate clinical indication for antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) for Resident (R) 18. This deficient practice placed these resident at risk for the potential of unnecessary psychotropic (altering mood or thoughts) medication administration thus leading to possible harmful side effects. Findings included: - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, atrial fibrillation (rapid, irregular heartbeat), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin, dementia (progressive mental disorder…

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 58 residents with 15 residents in the sample; all were reviewed for Minimum Data Set (MDS) completion. Based on record review and interview, the facility failed to complete the required Discharge or Death MDSs in a timely manner for the discharges of resident (R)7, R1, R6, and R2, and the deaths of R4 and R3. Findings included: - Review of MDSs on [DATE] at 04:36 PM for the following residents revealed: R3 was deceased on [DATE] with no Death in Facility MDS completed. R2 was discharged to rehab on [DATE] with no Discharge MDS completed. R4 deceased on [DATE] with no Death in Facility MDS completed. R1 was discharged home on [DATE] with no Discharge MDS completed. R6 was hospitalized on [DATE] and did not return to the facility; no Discharge MDS completed. R7 was discharged home on [DATE] with no Discharge MDS completed. Interview with Administrative Nurse F on [DATE] at 11:00 AM revealed, Those MDS should have been completed by the prior MDS Coordinator within 72 hours of discharge…

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 census totaled 58 residents, with 15 residents in the sample. Based on observation, interview, and record review, the facility failed to treat Resident (R) 9 with dignity and respect when a Certified Nurse Aid (CNA) used her personal phone, scrolled on personal social media, but did not engage with the resident she assisted with eating during dinner service. Findings included: - Observation of dining on 07/20/21 at 08:41 AM revealed CNA D at the assisted table playing/scrolling on her personal phone instead of engaging/feeding/cueing cognitive R9. Interview with CNA D on 07/20/21 at 08:45 AM revealed she stated, she worked night shift usually, but staff was not supposed to have their phones out when providing assistance with feeding. Interview with Administrative Nurse B on 07/20/21 at 08:46 AM revealed she expected that the staff's phones should not be out when providing any resident care; eating, dressing, toileting, etc. Interview during resident council on 07/21/21 at 02:30 PM revealed R167 stated, the staff used their personal phones all the time when caring/around…

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 58 residents, with 15 residents in the sample. Based on observation, interview, and record review, the facility failed to ensure that Residents (R) 47 and R267 had Advanced Directives/Code Status noted on the physical chart or on the Electronic Medical Record (EMR), which could have resulted in a resident receiving Cardiopulmonary Resuscitation (CPR) in the event of resident demise instead of the Do Not Resuscitate (DNR) as requested. Findings included: - Review of R47's pertinent diagnoses from Physician's Orders for diagnosis in the Electronic Medical Record (EMR) dated [DATE] revealed Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), Chronic Kidney Disease (CKD- a condition characterized by a gradual loss of kidney function over time), and Atherosclerotic Heart Disease (a condition which affects the arteries that supply the heart with blood; a buildup…

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 58 residents, with 15 residents included in the sample and one resident reviewed for discharge. Based on interview and record review, the facility failed to document the required discharge information in Resident (R) 67's medical record. Findings included: - Review of Resident (R) 67's Electronic Health Record (EHR) revealed the following diagnoses: muscle weakness and difficulty in walking. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R67 participated in the assessment. No active discharge planning occurred for the R67 to return to the community. Review of the Discharge MDS dated 06/19/21 revealed the facility did not perform a BIMS. R67's memory was ok, and she independently made decisions regarding tasks of daily life. Active discharge planning occurred for R67 to return to the community with no referral needed. Review of the Baseline Care Plan revealed R67 was admitted…

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 58 residents, with 15 residents included in the sample and one resident looked at for hospitalizations. Based on interview and record review, the facility failed to provide Resident (R) 6 or their representative a written notice for hospitalization. Findings included: - Review of R6's Electronic Health Records (EHR) revealed the following diagnosis: atrial fibrillation (rapid, irregular heartbeat) and benign prostatic hyperplasia/hypertrophy (non-cancerous enlargement of the prostate, which can lead to interference with urine flow, urinary frequency and urinary tract infections). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Review of an undated Care Plan revealed: R6 exhibited an altered level of consciousness (mental function fluctuation). Interventions included for staff to assess R6 for potential cause(s) for deterioration (lack of sleep, medication change,…

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 58 residents, with 15 residents included in the sample and one resident looked at for hospitalizations. Based on interview and record review, the facility failed to provide Resident (R) 6 or their representative with a bed-hold policy upon transfer to a hospital. Findings included: - Review of R6's Electronic Health Records (EHR) revealed the following diagnosis: atrial fibrillation (rapid, irregular heartbeat) and benign prostatic hyperplasia/hypertrophy (non-cancerous enlargement of the prostate, which can lead to interference with urine flow, urinary frequency and urinary tract infections). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Review of an undated Care Plan revealed: R6 exhibited an altered level of consciousness (mental function fluctuation). Interventions included for staff to assess R6 for potential cause(s) for deterioration (lack of sleep,…

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 58 residents, with 15 residents included in the sample and one resident reviewed for discharge. Based on interview and record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-and post-discharge medications, and develop a post-discharge plan of care, including discharge instructions for Resident (R) 67. Findings included: - Review of Resident (R) 67's Electronic Health Record (EHR) revealed the following diagnoses: muscle weakness and difficulty in walking. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R67 participated in the assessment. No active discharge planning occurred for the R67 to return to the community. Review of the Discharge MDS dated 06/19/21 revealed the facility did not perform a BIMS. R67's memory was ok, and she independently…

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 58 residents, with 15 included in the sample. One resident was reviewed for dialysis (the clinical purification of blood, as a substitute for the normal function of the kidney). Based on interview, observation, and record review, the facility failed to provide the necessary care and service to attain or maintain a resident's highest practicable physical well-being related to dialysis by not documenting assessments of Resident (R) 46's dialysis fistula (connection made by a vascular surgeon, of an artery to a vein) site. Findings included: - Review of R46's Electronic Health Record (EHR) revealed the following diagnoses: dependence on renal dialysis and end-stage renal disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R46 received dialysis treatments. A review of the undated Care Plan revealed: R46 had end-stage renal disease and required hemodialysis, which the facility…

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 58 residents, with 15 sampled and five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to follow the physician orders for hypertensive medications for Resident (R)49 and R11 and the facility failed to provide parameters for blood glucose (BG; blood sugar) for R49. Findings included: - Review of R49's Physician's Orders Electronic Medical Record dated 06/30/21 included a diagnosis of Diabetes Mellitus (DM; when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and hypertension (HTN; high blood pressure). A review of the admission Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. R49 received insulin (mediation that regulates the amount of glucose in the blood) seven out of a seven-day observation period. Review of the Care Area Assessment (CAA) dated 03/18/21…

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.