Martin Luther Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure assessed and care-planned adaptive equipment for eating was provided to promote independence and personal hygiene during meals for 1 of 1 residents (R20) reviewed who needed special utensil handles. Findings include: R20's quarterly Minimum Data Set (MDS), dated [DATE], identified R20 had moderate cognitive impairment and required set-up assistance with eating. On 6/9/25 at 2:35 p.m., R20 was observed lying in bed while in his room. R20 had a meal tray placed on a bedside table over him while lying down, and he had rice and beans spilled onto his chest. R20 took more bites of food from the provided tray which had a ceramic plate with regular, metallic utensils (i.e., fork, spoon) on it. The meal tray had a white-colored menu slip on it which recorded R20 as having a diabetic diet and no adaptive equipment was listed on it; however, on the wall immediately next to R20's bed was a white-colored sign which had black writing, Keep…

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 Based on observation, interview and document review, the facility failed to ensure a safe, comfortable and homelike environment for 2 of 4 shower rooms reviewed for cleanliness. Also, facility failed to ensure resident walls were in good condition for 3 of 3 resident rooms (R4, R28, and R77 ) reviewed for concerns of peeling and chipped paint. In addition, the facility failed to ensure a hallway handrail was secured firmly to wall outside resident room. Findings include: Shower Rooms: During observation and interview on 6/10/25 at 11:34 a.m., on the long-term care unit, the counter including the sink had two opened boxes of gloves and dry washcloths, a stack of opened 4x4 gauze, opened cotton tipped applicator, a used finger lancet, two unfolded towels with an opened one-gallon bottle of shampoo and body wash, and opened 8-ounce bottle of body lotion with screwcap not applied. The upper cabinet door next to sink had a door that was halfway opened hanging by one hinge rather than secured with two hinges. On 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 Based on observations and interviews, the facility failed to wear proper personal protective equipment for residents who were on droplet precautions for one of ten residents (R8) reviewed for personal protective equipment and precautions. Findings include: Observation on 1/2/25 at 4:11 p.m. showed R8 had a contact, droplet, and eye protection sign on the door. The sign indicated when entering R8's room, you should have clean hands, follow the droplet precautions by wearing a mask, eye protection if splashed/sprayed, gown, gloves, mask, and eye protection. Nursing assistant (NA)-A was observed walking into R8's room with a surgical mask, and reusable gown, no eye protection, or gloves. At 4:13 p.m., NA-A came out of R8's room and removed his gown but did not change his mask or wash his hands. R8's Face sheet printed on 1/2/25 indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of moderate protein-calorie malnutrition. R8's additional diagnoses included cold autoimmune hemolytic anemia 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 Based on interview and document review, the facility failed to monitor and obtain orders for surgical wound dressing changes for 1 of 3 residents (R1) reviewed for skin conditions. Findings include: R1's admission assessment dated [DATE], indicated R1 had a surgical incision on her back measuring 9.4 centimeters (cm) by 0.8 cm. R1's 5-day Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition. The MDS also indicated R1 had a surgical wound, but lacked indication of surgical wound care. R1's diagnoses included surgical aftercare following back surgery. R1's August Wound Treatment Record (WTR) indicated an order for daily dry dressing change to her back starting on 8/22/24. This was not completed because R1 was admitted to the hospital for an unrelated problem. The order was discontinued on 8/25/24, when R1 returned to the facility from the hospital. R1's readmission assessment dated [DATE] indicated a surgical incision to the mid-back measuring 9.4 cm by 1 cm. R1's Weekly Skin assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a comprehensive assessment for grab bars and implement interventions to ensure safety and mitigate the risk of entrapment or other injuries when using any mattress/bed types for 3 of 3 residents (R1, R2, R3) who had grab bars installed on their beds. Findings include: The facility reported incident (FRI) dated [DATE], identified R1 had been found with his head caught between the mattress and the grab bar. R1's face sheet dated [DATE], identified R1 admitted in [DATE] with diagnoses of Parkinson's, arthritis left knee, congestive heart failure, respiratory failure, morbid obesity, weakness, fracture of upper and lower end of left fibula, bacteremia, and repeated falls. R1's comprehensive minimum data set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, no delirium, no behaviors, no upper extremity impairment. Impairment of left lower extremity. R1 had frequent urinary incontinence and occasional bowel…

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 Based on interview and record review the facility failed to report an allegation neglect to the State Agency (SA) within 24 hours for 1 of 1 resident (R1). R1 was given the incorrect medications at the facility, which required R1 to be sent to the hospital for bradycardia (low heart rate), pain and anxiety. Findings include: R1's care plan dated 6/12/24 indicated R1's diagnoses included pneumonia, shortness of breath, saddle emolus of the pulmonary artery with acute cor pulmonale (a large blood clot that lodges in the pulmonary artery obstructing blood flow to both lungs), chronic pain, stage 3 kidney disease, hypertension (high blood pressure), cerebral infarction (stroke), hemiplegia and hemiparesis affecting the left side (weakness), osteoarthritis, and depression. R1's medication/treatment error report dated 6/15/24 at 9:15 a.m. indicated R1 was given Keppra (an anticonvulsant), metoprolol (a beta blocker to treat high blood pressure), and clopidogrel (a blood thinner). The description of the error indicated…

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 Based on observation, interview, and record review the facility failed to provide pharmaceutical services to meet the needs for 1 of 4 residents (R4) reviewed for medication administration. R4 had an over-the-counter medication on his tray table that he had been taking for approximately two weeks, the facility failed to monitor his intake of the medication. This medication had an interaction with a prescription medication R4 was taking. Finding include: R4's self-administration of medication assessment dated [DATE] indicated: -Required assistance for storing medications in a secure location. -Required assistance for opening and closing medication containers. -Could count not accurately tell time to know when medications need to be taken. -R4 did understand that skipping a medication dose is a refusal and staff will be notified when refusal has occurred. -Required assistance administering eye drops/ointments, topical lotions, ear drops, suppositories, subcutaneous injections, nasal sprays, and oral medications.…

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, interview and document review, the facility failed to ensure expired and visibly molding produce was disposed to prevent serving expired food. This had potential to affect all residents, visitors and staff who consumed food from the main kitchen. Findings include: During the initial kitchen tour with the dietary director (DD) on 4/15/24 at 12:10 p.m., the walk-in cooler was observed, which stored food served to all units of the facility and contained the following expired foods; an unopened bag of broccoli with a use-by date of 3/18/24, which was noticeably watery with brown spots, four unopened five-pound bags of brussels sprouts with a use-by date of 2/28/24, a cardboard box with approximately 25 cucumbers with noticeable denting open areas and white colored mold, a cardboard box 1/4 full of wrinkled, drooping asparagus with a use-by date of 3/22/24, three unopened bags of pre-chopped zucchini with a use-by date of 4/2/24 which was noticeably watery and browning, and two undated bags of precut potatoes which appeared watery with white mold spots. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure appropriate infection control measures were implemented for direct resident care for 1 of 1 residents (R230) who was placed on enhanced barrier precautions. In addition, the facility failed to ensure clean personal and facility laundry was protected during transport and storage outside resident rooms. This had the potential to affect all 132 residents who utilized facility provided laundry services. Findings include: PPE Use The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Ref: QSO-24-08-NH dated March 20, 2024, state Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities. In addition, EBP are indicated for residents with any of the following: -Infection or colonization with…

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

Based on observation and interview the facility failed to ensure two medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect twenty residents that resided on those units. Findings include: Facility map provided to surveyors immediately after entrance on 4/15/24 identified the Bridgeway unit of facility as the Transitional Care Unit (TCU) of the facility. This includes rooms 110-129. During observation on 4/16/24 at 8:19 a.m., an unattended medication cart in the west section of the TCU was observed to be unlocked with no staff visible. During interview with registered nurse (RN)-A on 4/16/21 at 8:21 a.m., RN-A stated he was responsible for the unlocked unattended medication cart. RN-A stated, when I leave med cart I should hide the resident info on the laptop and lock med cart. During interview with charge nurse, RN-C on 4/17/24 at 8:08 a.m., RN-C stated, When you leave [it], med cart is to be locked and screen locked for patient privacy.…

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, interview and document review, the facility failed to ensure timely assistance with elimination care was provided, when requested, to promote dignity and reduce the risk of complication (i.e., incontinence) for 1 of 2 residents (R182) reviewed for dignity with personal care. Findings include: R182's N Adv Brief Interview For Mental Status (BIMS) Evaluation (a screening tool used to determine cognition), dated 4/10/24, identified R182 had intact cognition. On 4/15/24 at 5:45 p.m., R182 was observed lying in bed while in her room. R182 was interviewed, and explained she had admitted to the care center about a week prior and was mostly bed-ridden due to a sustained injury adding she could only use a bed pan for various elimination needs due to the immobility. R182 stated the biggest complaint about the care center was staff who respond to her calls for assistance, and then express they will be right back but not then return timely, if at all. R182 stated this had happened many times since she admitted . On 4/17/24 at 8:46 a.m., medication administration 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.

Based on observation, interview and document review, the facility failed to ensure resident medical records which contained private, medical, and personal information were kept private and not accessible to unauthorized personnel for 2 of 2 residents (R230 and R6) reviewed for privacy. Findings include: During observation on 4/16/24 at 8:19 a.m., an unattended medication cart in the hallway in the west side of the Transitional Care Unit (TCU) with laptop open to R230's medication list was observed. During interview with registered nurse (RN)-A on 4/16/21 at 8:21 a.m., RN-A stated he was responsible for the unattended TCU medication cart with R230's medication list visible on the laptop screen. RN-A stated, when I leave med cart I should hide the resident info on the laptop and lock med cart. During observation and interview on 4/18/24 at 1:27 p.m., an unattended medication cart with a laptop open to R6's electronic medical record was observed in the 2nd floor east hallway of the long term care unit of facility. RN-G approached medication cart with a rolling vital sign equipment 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 Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R64) reviewed for activities of daily living (ADLs) who was dependent on staff for their care. Findings include: R64's quarterly Minimum Data Set (MDS) dated [DATE], indicated R64 had moderate cognitive impairment, needed substantial/maximal assistance with personal hygiene, dressing, eating, oral hygiene and was dependent on toileting and showering. R64's MDS did not indicate behaviors or refusal of cares. R64's Clinical Diagnosis Report printed 4/18/24, indicated diagnoses of vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), type II diabetes mellitus with diabetic neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), major depressive disorder, peripheral vascular disease (circulatory condition 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 Based on observation, interview, and document review, the facility failed to ensure wound prevention treatment was implemented for 1of 1 resident (R36) who had a history of bilateral heel pressure areas and risk for skin breakdown. Findings include: R36's annual Minimum Data Set (MDS) dated [DATE], indicated R36 had moderate cognitive impairment, no delirium, or behaviors, and did not refuse cares. MDS indicated, R36 needed moderate assistance with upper body dressing, toileting, oral hygiene, and bathing. R36 needed maximal assistance with lower body dressing, putting on/taking off footwear, personal hygiene, and transfers. MDS also indicated, R36 was at risk to develop pressure areas. R36's Clinical Diagnosis Report printed 4/17/24, indicated diagnoses of type II diabetes mellitus (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), diabetes chronic kidney disease (a gradual loss of kidney function), vascular dementia…

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 Based on observation, interview and document review, the facility failed to comprehensively reassess after repeated refusals of an ambulation program and, if needed, develop interventions to reduce the risk of mobility loss for 1 of 1 resident (R36) reviewed for mobility. Finding include: R36's annual Minimum Data Set, dated (MDS) 4/8/24, indicated R36 had moderate cognitive impairment, no delirium, or behaviors, and did not refuse cares. MDS indicated, R36 needed moderate assistance with upper body dressing, toileting, oral hygiene, and bathing. R36 needed maximal assistance with lower body dressing, putting on/taking off footwear, personal hygiene, and transfers. MDS also indicated, R36 was at risk to develop pressure areas. R36's Clinical Diagnosis Report printed 4/17/24 indicated diagnoses of type II diabetes mellitus (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), diabetes chronic kidney disease (means a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the use of bilateral, bed-mounted grab bars was comprehensively reassessed and, if needed, develop interventions to ensure safety while in bed for 1 of 1 resident (R62) reviewed who developed seizures after admission to the care center. Findings include: R62's admission Minimum Data Set (MDS), dated [DATE], identified R62 had intact cognition, demonstrated no delusional thinking during the review period, and required supervision or touch-level assistance with mobility-related activities of daily living (ADLs; i.e., rolling left to right, lying to sitting). Further, the MDS outlined a section labeled, Section I - Active Diagnoses, with R62 being recorded as not having a seizure disorder or epilepsy. R62's most recent Device Assessment and Consent - V2, dated 3/26/24, identified an admission evaluation was being completed for two devices which included, 9. Grab Bars - Bilateral. The evaluation outlined R62 was not prevented from…

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 Based on observation, interview, and document review the facility failed to ensure staff provided cares according to standard of practice for gastrostomy tube care for 1 of 1 residents (R230) reviewed for tube feedings. Findings include: R230's admission Minimum Data Set (MDS) dated [DATE], identified R230 dependent on helper (staff) for all effort of activity or requires assistance of 2 or more helpers for oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, personal hygiene and mobility. In addition, R230 diagnoses included stroke (cell death to portions of the brain causing loss of functioning), aphasia (inability to speak well), hemiplegia/hemiparesis (partial paralysis) of right dominant side, respiratory failure, dysphagia (inability to swallow), and had a gastrostomy tube (feeding tube to stomach) for all nutrition and medication administration. R230's care plan (CP) dated 2/23/24, documented R230 Dependent with tube feeding and water flushes. And Enteral feed: Water…

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, interview, and document review, the facility failed to ensure 2 of 3 unit refrigerators for resident use were maintained in a clean and sanitary manner. In addition, the facility failed to ensure a safe temperature of between 36 degrees Fahrenheit (F) and 41 degrees F was maintained in 2 of 3 resident's refrigerators. In addition, the facility also failed to date food in 2 of 3 resident's refrigerators. Findings include: On 8/2/23 at 11:00 a.m. the BW resident refrigerator was observed with dietary supervisor (DS)-A. A tan, purple spillage was observed inside of the door on two shelves, two undated opened ice-cream containers were observed, yellow liquid in 12 ounce opened cup undated, and build up of an unidentified brown colored substance was noted throughout the entire BW resident refrigerator. The temperature of the refrigerator was 44 degrees Fahrenheit (F). DS-A verified the observations. On 8/2/23 at 11:30 a.m. the FC resident refrigerator was observed with dietary director (DD)-A. An unidentified brown colored substance was observed on the second shelf…

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 Based on observation, interview, and document review, the facility failed to ensure 3 of 3 commercial food cooling devices (i.e., refrigerators, freezers) had ongoing monitoring of temperature and function to reduce the risk of potential foodborne illness; failed to ensure 1 of 2 commercial can openers was kept in a clean and sanitary manner; and failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk of cross-contamination. These findings had potential to affect all 123 residents, staff, and visitors, who consumed food prepared from the main production kitchen. Findings include: On 3/20/23 at 12:14 p.m., an initial kitchen tour was completed, and the following items were identified: 1) A commercial [NAME] can opener was attached to the counter by the oven range(s). The blade of the opener had copious amounts of a dried black debris present along the bottom of the blade, along with red and tan-colored debris present along the top of the blade. 2) A single Continental…

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 Based on observation, interview, and document review, the facility failed to accommodate resident needs by ensuring call light were accessible for 5 of 5 residents (R11, R20, R53, R61, R426). Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had moderate cognitive deficits, was independent with eating and required extensive assistance with all other activities of daily living (ADLs). R11's Care Area Assessment (CAA) dated 11/16/22, indicated R11 triggered for visual function, urinary incontinence, falls, and psychotropic medication use. R11's care plan undated, indicated R11 had a self-care deficit and limited mobility weakness, a history of falls with a rib fracture, and blindness. Interventions included encouraging R11 to use the call light for assistance. R11 also had a fall related to poor balance and an unsteady gait. Interventions included keeping frequently used items within his reach and encouraging R11 to call for assistance when in pain. R11 was also on oxygen therapy…

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 Based on interview, observation, and document review the facility failed to safely secure medications that were left at the bedside in reach for 3 of 3 residents (R29, R20, R53) reviewed for self-administration of medication (SAM). Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was cognitively intact. R29's Self Administration of Medications assessment dated [DATE], indicated R29 was not safely able to self-administer medications. R29's orders dated 6/22/22, indicated diclofenac sodium gel 1% (medication used to relieve joint pain from arthritis), apply to bilateral knees topically four times a day for knee pain. During observation on 3/20/23 at 2:00 p.m., R29 was lying in bed, sitting up with her tray table over her bed. A tube of diclofenac sodium gel 1% was within reach on R29's tray table. When interviewed on 3/20/23 at 2:00 p.m., R29 stated the diclofenac sodium gel was often left in the room, and this time since approximately 11:30 a.m. R29 stated she would have found…

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 Based on observation, interview, and document review the facility failed to ensure a comprehensive assessment and person-centered care plan was completed for 1 of 1 residents (R11) who was legally blind. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had moderate cognitive deficits, was independent with eating and required extensive assistance with all other activities of daily living (ADLs). R11's diagnoses included heart failure, legal blindness, insomnia, and depression. R11's Care Area Assessment (CAA) dated 11/16/22, indicated R11 triggered for visual function, urinary incontinence, falls, and psychotropic medication use. R11's care plan undated, indicated R11 preferred to be notified and invited to larger group activities. Interventions included providing R11 with a monthly activity calendar although R11 was legally blind and unable to read. R11 was at risk for pain related to a fall with a rib fracture. Non-pharmacological interventions included walking/ambulation 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 Based on interview, observation, and document review, the facility failed to provide shaving assistance for 2 of 2 residents (R72, R78), and failed to provide scheduled baths for 1 of 1 resident (R87) reviewed for activities of daily living (ADL). Findings include: R72's admission Minimum Data Set (MDS) dated [DATE], indicated R72 had moderate cognitive impairment, required extensive assistance with most activities of daily living (ADLs), and had medical diagnosis of diabetes type II and urinary tract infection. R72's care plan indicated R72 had an ADL self-care deficit and required assistance from one staff member to complete personal hygiene. During observation on 3/20/23, at 3:37 p.m. R72 was noted to have long chin hairs approximately one inch long. During observation on 3/21/23, at 2:55 p.m. R72 was noted to have long chin hairs approximately one inch long. During observation and interview on 3/22/23, at 7:29 a.m. R72 still had long chin hairs after receiving a shower by facilty staff that morning. R72…

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 Based on interview, observation, and document review the facility failed to ensure staff could communicate effectively to 1 of 1 resident (R51), a non-English speaking resident, reviewed for communication. Findings include: R51's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, the preferred language was Vietnamese and needed/wanted an interpreter for communication. The MDS further indicated no behaviors, R51 required assistance of two staff for bed mobility and transfers, and assistance of one staff for eating, toileting and personal hygiene. R51's care plan updated 2/13/23, indicated to utilize Vietnamese interpreter as needed and at times, use interpreter to help with communication barriers but lacked indication when interpreter services were required. The care plan indicated R51 had a communication resource book to use with pictures and words in Vietnamese. When interviewed on 3/20/23, at 6:33 p.m. FM-E with FM-F on the phone, stated staff cannot communicate with R51 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 Based on observation, interview, and document review, the facility failed to ensure a resident with limited mobility and on a walking program received appropriate assistance to maintain or improve mobility for 1 of 1 residents (R78) reviewed for mobility. Findings include: R78's admission Minimum Data Set (MDS), dated [DATE], indicated R78 had mild cognitive impairment, needed limited physical assistance from one staff member for most activities of daily living (ADLs) including walking, and medical diagnoses which included aspiration pneumonia due to inhalation of food or fluids, adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and unspecified dementia. R78's care plan indicated R78 had limited physical mobility related to weakness and was on a nursing…

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 Based on observation, interview, and document review the facility failed to comprehensively assess, create and implement intervention to promote the safety for 1 of 1 residents (R26) who resided in the memory care unit, had an unwitnessed fall, and continued to ambulate without assistance. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 was unable to complete the Brief Interview for Mental Status (BIMS). The staff assessment indicated R26 had severe cognitive deficits. R26 was independent for eating and required extensive assistance of one staff for all other activities of daily living (ADLs). R26 also required limited assistance of one person physical assist for walking. R26's facesheet indicated R26's had diagnoses including aphasia (a brain disorder affecting language and comprehension), Alzheimer's disease, dementia with behavioral disturbance, diabetes, corns and callosities (a thick, hard and painful raised bump), pain in right and left feet and toes, right and left…

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 interview, observation and document review the facility failed to assess and monitor for complications per standard of practice before and after dialysis for 1 of 1 resident (R35) reviewed for dialysis care. Findings include: R35's face sheet printed 3/23/23, included diagnoses of end stage renal disease, dependence on renal dialysis, pulmonary hypertension, atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart), heart failure, and oxygen therapy due to respiratory failure. R35's provider orders printed 3/23/23, failed to indicate any assessment of the dialysis port and care prior to and following the three times per week hemodialysis appointments. R35's care plan dated 3/23/23, stated R35 had intact cognition and required assistance of two staff for toileting and transferring into his electric wheelchair. In addition, R35 was scheduled for dialysis three times per week. During interview with R35 on 3/20/23 at 4:44p.m., R35 stated facility staff have not looked at his dialysis port prior to or after his three day per week hemodialysis…

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 Based on observation, interview, and document review the facility failed to provide food choices to 1 of 1 residents (R11) during meal service. This had the potential to affect all 15 residents residing in the memory care unit. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had moderate cognitive deficits, was independent with eating and required extensive assistance with all other activities of daily living (ADLs). R11's Care Area Assessment (CAA) dated 11/16/22, indicated R11 triggered for visual function, urinary incontinence, falls, and psychotropic medication use. R11's care plan undated, indicated R11 had personal preferences with a goal of having his preferences followed. R11 had a potential for cognitive impairment and ranged from intact to moderate cognition. Interventions included providing R11 opportunity to make choices. R11 had potential for nutritional problems related to heart disease, edema, and legal blindness. Interventions included assisting R11 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure adaptive equipment was provided as care planned to promote independent, easier eating abilities for 1 of 1 resident (R112) observed to have difficulty drinking from regular (i.e., non-handled) glassware. Findings include: R112's quarterly Minimum Data Set (MDS), dated [DATE], identified R112 had moderate cognitive impairment and required supervision with set-up assistance for eating. R112's Nutritional Assessment 4.0 - V2, dated 12/29/22, identified R112 consumed a regular diet with thin liquids. A section labeled, Physical Functioning, identified R112 required set-up assistance for feeding and a checkmark was placed next to a subsection labeled, Adaptive equipment required, which outlined, OT [occupational therapy] recommending 2-handle cup. Further, the section of the assessment labeled, Analysis, outlined R112 demonstrated no difficulties with chewing or swallowing and was able to feed himself . with meal set up and uses a 2…

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 Based on interview and document review, the facility failed to ensure a resident's immunization status was verified or documented for 1 of 5 residents (R118) reviewed for immunizations. Furthermore, the facility failed to ensure the influenza vaccine was offered or received for 1 of 5 residents (R118) in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R118's admission Minimum Data Set (MDS), dated [DATE], indicated R118 was admitted to the facility on [DATE] and had moderate cognitive impairment. R118's immunization record showed no evidence of receiving, or being offered, the influenza vaccine. During an interview on 3/23/23 at 1:29 p.m., R118 stated she was not offered any vaccines when she admitted to the facility, including the influenza vaccine. During interview on 3/23/23 at 10:00 a.m., the infection preventionist (IP) stated she was responsible for verifying residents' immunization status through the Minnesota Immunization Information Connection (MIIC) when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a resident's COVID immunization status was verified or documented for 1 of 5 residents (R118) reviewed for immunizations. Furthermore, the facility failed to ensure the COVID vaccine was offered or received for 1 of 5 residents (R118) in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R118s admission Minimum Data Set, dated [DATE], indicated R118 was admitted to the facility on [DATE] and had moderate cognitive impairment. R118's immunization record showed no evidence of receiving, or being offered, the COVID vaccine. During an interview on 3/23/23 at 1:29 p.m., R118 stated she was not offered any vaccines when she was admitted to the facility, including the COVID vaccine. During interview on 3/23/23 at 10:00 a.m., the infection preventionist (IP) stated she was responsible for verifying residents' immunization status through the Minnesota Immunization Information Connection (MIIC) when they 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.