Park River Healthcare And Rehabilitation Center Ll

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide assistance with personal cares, for 2 of 2 residents (R23 and R98) reviewed for assistance with activities of daily living (ADLs-including placement of hearing aids, set up for eating, and personal grooming including shaving) for dependent residents. Findings include: R98's Nursing Assessment/Initial Care Plan, initiated on 4/8/26, indicated R98 was admitted with encephalopathy (any disorder or disease that affects brain function. It can lead to altered mental status, memory loss, personality changes, and in severe cases, coma) and was alert and oriented times one to two (person and/or person and place), demonstrated forgetfulness, and was unable to use call light to summon staff. The nursing assessment/initial care plan identified R98 required assistance with mobility, transfers, personal dressing, grooming, and bathing. R98's care plan, initiated on 4/14/26, identified R98's additional medical diagnoses included: depression,…

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 services were provided in accordance with professional standards of practice and physician orders, including failure to apply compression stockings as ordered and failure to ensure accurate documentation of care provided, for 2 of 2 residents (R27 and R46) reviewed for quality of care. Additionally, the facility failed to ensure proper positioning in her wheelchair for 1 of 1 residents (R23) observed leaning over in their wheelchair. Findings include: R27R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 had intact cognition and required assistance with activities of daily living (ADL)'s. R27's diagnoses included peripheral vascular disease (PVD; poor circulation due to narrowed blood vessels), localized edema (swelling caused by fluid buildup in tissues), and dependence on supplemental oxygen (requires additional oxygen to maintain adequate oxygen levels). The MDS also indicated R27 was receiving oxygen…

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 consistently provide assistance to complete range of motion (ROM) as outlined in plan of care for 1 of 2 residents (R11) reviewed for range of motion. Findings include: R11's comprehensive/annual Minimum Data Set assessment completed 2/28/26, identified R11 was admitted to the facility on [DATE] with multiple medical diagnoses which included vascular dementia, aphasia (difficulty with speaking), hemiplegia/hemiparesis (loss of mobility on one side of the body), depression and anxiety, and personality change due to physiological condition. Although R11 was identified as having cognitive impairments, it is noted R11 was able to understand others and make self-understood. R11 was identified as having received personal assistance with all aspects of care.R11's care plan last revised on 6/5/25, identified R11 had an alteration in neurological status related to a stroke and history of temporal lobectomy (procedure that removes the front part…

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 record review and interview, the facility failed to ensure the recommendations from the monthly medication regimen review (MRR) conducted by the consultant pharmacist were reviewed and acted upon in a timely manner, in accordance with professional standards of practice, for 2 of 6 residents reviewed for unnecessary medications (R9 and R65).Findings include: R65's quarterly Minimum Data Set (MDS) assessment, completed on 2/23/26, identified R65 was admitted to the facility on [DATE] had impaired cognition, and required assistance with activities of daily living (ADL's-eating, dressing, grooming, bathing, and mobility). R65's medical diagnoses included: Alzheimer's disease and non-Alzheimer's dementia, anxiety, depression, hypertension (high blood pressure), orthostatic hypotension (a drop in blood pressure which occurred with a change in position and adult failure to thrive. A review of the consulting pharmacist reports was completed from the time of R65's admission date of 11/21/25. It was noted 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 observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice, including failure to follow physician orders to monitor blood pressure and pulse parameters prior to administration of a beta-blocker medication, for 1 of 1 resident (R16) reviewed for unnecessary medications.Findings include:R16's admission Minimum Data Set (MDS) dated [DATE], identified R16 had intact cognition and was independent with activities of daily living (ADL)'s. R16's diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular heart rhythm), coronary artery disease (narrowing or blockage of the heart's blood vessels), heart failure (a condition where the heart cannot pump blood effectively), and end stage renal disease (advanced kidney failure requiring dialysis).Review of R16's physician orders printed 4/22/26, identified an order for Metoprolol Tartrate 50 MG (milligram), give 50 mg by mouth two times a day…

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 recommended influenza, pneumococcal, and Covid-19 vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 2 of 5 residents (R16 and R19) reviewed for immunizations. Findings include: R16's comprehensive/admission Minimum Data Set (MDS) assessment, completed on 4/2/26, indicated he was admitted to the facility on [DATE], and was cognitively intact, and was independent with activities of daily living (ADL's-dressing, grooming, mobility, and hygiene), however, used a walker/wheelchair. R16's medical diagnoses included end stage renal disease (ESRD-a chronic kidney disease where kidneys can no longer function properly)with dependence on renal dialysis (a process to help the body rid the wastes the kidney is no longer able to remove), multiple cardiac diseases including coronary artery disease, heart failure, hypertension, and aortic stenosis. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide supervision during mealtimes for 3 out of 3 residents (R21, R62 and R375) reviewed for dining. Finding includes: R21's significant change Minimum Data Set (MDS), dated [DATE], identified R21 had intact cognition required supervision or touching assistance with eating. R21's diagnoses included cerebral palsy (neurological disorder that affect movement and posture), dementia and malnutrition. MDS also identified R21 was on a mechanically altered diet with thickened liquids. R62's admission MDS dated [DATE], identified R62 had moderate cognitive impairment and required supervision or touching assistance with eating. R62's diagnoses included progressive neurological condition (condition where there is a gradual and ongoing decline in neurological function, impacting various bodily systems and functions), Alzheimer's disease, dementia, Parkinson's disease and malnutrition. R375's admission MDS dated [DATE], identified R375 had intact cognition 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 and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended for 1 of 1 medication cart located on the west unit. Findings include: R51's quarterly Minimum Data Set (MDS) dated [DATE], identified R51 had severe cognitive impairment and required assistance with activities of daily living (ADL)'s. During observation on 6/11/25 at 8:52 a.m., R51 was sitting at the medication cart on west unit, fidgeting with drawers and things on top of medication cart. Staff approached R51 and asked him to not touch things and that staff were watching him. During observation on 6/11/25 at 9:00 a.m., medication cart was sitting in the hallway in the fireside room and was unlocked. R51 was wandering around the area touching and fidgeting with items. During observation and interview on 6/11/25 at 9:03 a.m., licensed practical nurse (LPN)-E returned to medication cart and locked cart. LPN-E confirmed medication cart was unlocked and stated, it…

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 honor a resident's right to make choices about aspects of care related to the method of blood glucose monitoring for 1 of 1 residents (R61) reviewed for diabetic care. Findings include: R61's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with a diagnoses of diabetes mellitus (DM) with neuropathy (pain, numbness, tingling, and muscle weakness, primarily in the hands and feet), aphasia (language disorder that affects the ability to speak) following cerebrovascular infarct (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), cancer (right breast), hypertension (high blood pressure), hyperlipidemia (high cholesterol), arthritis, depression, and cataracts. R61 required extensive assistance for most activities of daily living (ADLs) and R61 was usually understood. R61's admission MDS dated [DATE] (admission) identified resident was cognitively intact, indicating…

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 an electric recliner was not used in a manner to restrain resident for 1 of 1 resident (R375) reviewed for restraints. Findings include: R375's admission Minimum Data Set (MDS) dated [DATE], identified R375 had intact cognition and required assistance with all activities of daily living (ADLs). R375's diagnoses included cancer, atrial fibrillation (heart rhythm disorder), heart failure (occurs when the heart muscle can't pump enough blood to meet the body's needs), hypertension (high blood pressure), benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), pneumonia and malnutrition. MDS also indicated R375 did not use any restraints. R375's care plan reviewed 5/27/25, identified R21 had limited physical mobility and was a fall risk related to activity intolerance, confusion, fatigue and impaired balance. Staff were directed to assist R375 with an assist of one and a gait belt or all transfers. R375's care…

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 order of as-needed (PRN) psychotropic medication was limited to 14-days or extended to a specific date with supporting rationale provided by the medical provider for 2 of 5 residents (R65 and R60) reviewed for unnecessary medication use. Findings include: R65's significant change Minimum Data Set (MDS), dated [DATE], identified R65 had intact cognition and required assistance with activities of daily living (ADL's) including dressing, grooming and bathing. R65's medical diagnoses included cancer, diabetes mellitus (a disease which impacts how the body processes sugar), arthritis (painful inflammation of joints), and malnutrition (poor nutrition impacted by either intake or by how the body utilizes the food ingested. A review of R65's medication administration record (MAR), dated 6/10/25, identified the following order: Prochlorperazine Maleate (an anti-psychotic medication frequently used to treat nausea/vomiting) Oral Tablet…

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 the care plan included management and monitoring of urinary catheter for 1 of 2 residents (R375) reviewed for catheter use. Findings include: R375's admission Minimum Data Set (MDS) dated [DATE], identified R375 had intact cognition and required assistance with all activities of daily living (ADLs). R375's diagnoses included benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland). R375's MDS also indicated R375 had a urinary catheter. R375's electronic health record (EHR) included an order for Foley catheter 16 F (French) with 10 mL (milliliter) bulb with a start date of 5/22/25. R375's care plan, reviewed on 6/10/25, failed to include Foley catheter use or to monitor for side effects of the treatment. During interview on 6/12/25 at 1:43 p.m., licensed practical nurse (LPN)-D stated R375 had a catheter which should be monitored for signs and symptoms of infection. During interview on 6/12/25 at 2:28 p.m., the director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to revise the care plan to include non-pressure wounds for 1 of 1 residents (R27) in the sample whose care plan was reviewed. Findings include: R27's annual minimum data set (MDS) dated [DATE], indicated R27 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's). R27's face sheet printed 6/11/25, indicated R27 had diagnoses which included chronic respiratory failure, congestive heart failure, heart disease, osteoarthritis, anemia, hypertension, and Alzheimer's disease. R27's care plan undated, indicated R27 had a potential for alteration in skin related to bedfast, immobility and incontinence. Interventions included lotion dry skin, staff were directed to assist with incontinence care, heels elevated off bed surface, R27 preferred covers off feet, and staff were directed to monitor for changes in skin integrity with bathing, cares and prn (as needed), report changes to nurse. However, care plan failed…

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 activities of daily living (ADLs) for 2 of 3 resident (R3 and R375) who were dependent on staff for assistance with ADL's. Findings include: R375 R375's admission MDS dated [DATE], identified R375 had intact cognition and required assistance with all ADL's. R375's diagnoses included cancer, atrial fibrillation (heart rhythm disorder), heart failure (occurs when the heart muscle can't pump enough blood to meet the body's needs), hypertension (high blood pressure), benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), pneumonia and malnutrition. R375's care plan lacked evidence of resident's shaving preferences as well as direction for staff for assistance with personal hygiene and grooming. During observation on 6/9/25 at 1:13 p.m., R375 had white facial hair on cheeks, chin and upper neck approximately ½ inch long. During observation on 6/11/25 at 8:42 a.m., R375 continued to have facial hair on cheeks,…

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 routine assistance to properly position a who was dining in bed to promote comfort and ease in eating for 1 of 1 residents (R37) reviewed for positioning. In addition, the facility failed to consistently assess and monitor a wound for 1 of 1 residents (R27) reviewed for wound care. Further, the facility failed to monitor blood pressures and pulse for 1 of 1 residents (R19) who had parameters for medication administration. Findings include: R37 R37's annual Minimum Data Set (MDS) completed on 5/2/25, identified R37 had moderate cognitive impairment. R37 exhibited no signs of delirium, such as inattention, disorganized thinking, altered level of consciousness. R37 was able to eat independently once she is set up. R37 required assist to roll from left to right. R37 was fully dependent on others to transfer to/from bed. R37 was wheelchair bound. R37's medical diagnoses included hemiplegia/hemiparesis (loss of movement on one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure developed pressure ulcers were comprehensively assessed and monitored to ensure healing and prevent complications for 1 of 1 residents (R3) reviewed for pressure ulcer care. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R3's diagnoses included progressive neurological conditions, multiple sclerosis (chronic, often debilitating disease that affects the central nervous system - brain and spinal cord), peripheral vascular disease (condition affecting blood vessels outside of the heart and brain), neurogenic bladder (bladder dysfunction caused by nerve damage that disrupts the normal communication between the bladder and the brain), arthritis, Alzheimer's disease, non-Alzheimer's Dementia, malnutrition and localized edema (swelling caused by excess fluid trapped in the body's tissues. MDS indicated a risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure catheter care was provided in a manner to prevent potential urinary tract infection (UTI) for 1 of 1 resident (R3) reviewed for catheters. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R3's diagnoses included progressive neurological conditions, multiple sclerosis (chronic, often debilitating disease that affects the central nervous system - brain and spinal cord), peripheral vascular disease (condition affecting blood vessels outside of the heart and brain), neurogenic bladder (bladder dysfunction caused by nerve damage that disrupts the normal communication between the bladder and the brain), arthritis, Alzheimer's disease, non-Alzheimer's Dementia, malnutrition and localized edema (swelling caused by excess fluid trapped in the body's tissues. MDS indicated R3 had an indwelling catheter.…

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 post-dialysis assessment and monitoring was completed for 1 of 1 resident (R19) reviewed for dialysis. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had intact cognition. R19s diagnoses included end stage renal disease (final stage of chronic kidney disease), anemia (condition where the body doesn't have enough healthy red blood cells or hemoglobin to carry sufficient oxygen to the body's tissues), coronary artery disease (condition where the arteries supplying blood to the heart become narrowed or blocked), heart failure (occurs when the heart muscle can't pump enough blood to meet the body's need), hypertension (high blood pressure), peripheral vascular disease (condition affecting blood vessels outside of the heart and brain), diabetes mellitus (group of metabolic diseases characterized by high blood sugar levels, resulting from either the body's inability to effectively use the insulin it produces),…

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 pharmacist consultant recommendations were acted upon for 1 of 5 residents (R65). In addition, the facility failed to ensure consulting pharmacist identified irregularities in the monthly drug regimen reviews for 3 of 5 residents (R65, R25 and R60) reviewed for unnecessary medications. Findings include: R65's significant change Minimum Data Set (MDS) dated [DATE], identified R65 had intact cognition and remained unchanged from baseline assessment. R65 received assistance with activities of daily living (ADLs) including dressing, grooming and bathing. R65's medical diagnoses included cancer, diabetes mellitus (a disease which impacts how the body processes sugar), arthritis (painful inflammation of joints), malnutrition (poor nutrition impacted by either intake or by how the body utilizes the food ingested), pain in shoulder, cervicalgia (neck pain), and chronic pain. R65's care plain initiated 2/17/25, identified R65 had a nutritional problem…

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 antipsychotic medications were appropriately monitored in accordance with the standard-of-care laboratory testing to help reduce the risk of medication side effects for 1 of 5 residents (R25) reviewed for unnecessary medication use. R25's annual minimum data set (MDS) dated [DATE], indicated R25 was cognitively intact and was totally dependent on staff for activities of daily living (ADLs). R25 had diagnoses of bipolar disorder, adult failure to thrive, anxiety, major depression, hyperlipidemia, spinal stenosis, bradycardia, and myocarditis. R25's Order Summary Report dated 6/10/25, identified orders for Rosuvastatin (statin medication used to lower cholesterol) with a start date 4/23/24, Aripiprazole (an antipsychotic) for paranoid delusions, Venlafaxine (an antidepressant) for bipolar disorder, and Olanzapine (an antipsychotic) for bipolar disorder. R25's medical record lacked evidence of laboratory (lab) monitoring of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to consistently implement hand hygiene following glove use for 1 of 1 residents (R36) observed for personal cares. In addition, facility failed to ensure proper personal protective equipment (PPE) was used when providing cares for 1 of 1 resident (R3) reviewed for enhanced barrier precautions (EBP). Findings include: R36 R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 had impaired cognition never/rarely made decisions. R36 was dependent on staff for toileting, dressing, and bathing. R36's medical diagnoses included non-traumatic brain dysfunction (occurs due to internal factors affecting the brain, such as strokes, lack of oxygen, or infections), unspecified dementia (a decline in cognitive function severe enough to interfere with daily life), hemiplegia (one sided weakness), aphasia (difficulty with speaking), and speech and language deficits following cerebral infarction (stroke). R36's care plan initiated…

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 consistently place the call light within reach for 1 of 1 residents (R10), who was reviewed for call light use. Findings include: R10's significant change Minimum Data Set (MDS) assessment completed 2/7/25, indicated R10 had significant cognitive impairment. R10 was noted to lack indicators of delirium, including inattention, disorganized thinking, or altered level of consciousness. The assessment lacked answers for the question Made decisions regarding tasks of daily life. The MDS identified R10 was to be interviewed regard daily and activity preferences. R10's medical diagnoses included non-traumatic brain dysfunction (occurs due to internal factors affecting the brain, such as strokes, lack of oxygen, or infections), vascular dementia, hemiplegia/hemiparesis (weakness on one side of the body), seizure disorder/epilepsy, anxiety disorder, depression, systemic lupus (a chronic autoimmune disease where the immune system attacks healthy tissues, leading to inflammation and damage across various body…

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 clarify with the resident and/or the resident's representative their current advance directive when there was conflicting documentation in the record for 1 of 24 residents (R328) reviewed for advance directives. This has the potential to affect all residents. Findings include: R328 diagnosis upon admission included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements), adult failure to thrive (a condition where an older adult loses appetite, weight, and interest in activities), and chronic kidney disease (a condition that impairs kidney function and causes kidney damage). As well, R328 had a BIMS (Brief interview of mental status) of 15 indicating intact cognition. Hospital H&P (history and physical) dated 3/1/24, indicated code status as full code and noted as alert and oriented. Hospital Discharge summary dated [DATE], indicated admission H&P valid: Yes, and treatment options as DNR (Do not resuscitate). However,…

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 consulting pharmacist identified irregularities in the monthly drug regimen reviews for 4 of 5 residents (R4, R25, R35, and R69) reviewed for unnecessary medications. This has the potential to affect all residents taking psychotropic medications. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderately impaired cognition and diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, anxiety disorder, depression, neuralgia and neuritis, insomnia, age-related osteoporosis, visual hallucinations, muscle weakness, and long-term use of anticoagulants as well as daily use of antipsychotic and antidepressant medications. R4's Order Summary Report dated 3/14/24, identified orders for Seroquel (an antipsychotic) for dementia with hallucination and agitation with a start date 10/19/23 and Bupropion (an antidepressant) for major depressive disorder with a start date of 10/21/23. R4's care plan 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 interview and document review, the facility failed to ensure monitoring for potential cardiovascular and neurological adverse consequences, and obtaining informed consent with use of psychotropic medications for 4 of 5 residents (R4, R25, R35, and R69) reviewed for unnecessary medications. This has the potential to affect all resident on psychotropic medications. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderately impaired cognition and diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, anxiety disorder, depression, neuralgia and neuritis, insomnia, age-related osteoporosis, visual hallucinations, muscle weakness, and long-term use of anticoagulants as well as daily use of antipsychotic and antidepressant medications. R4's Order Summary Report dated 3/14/24, identified orders for the psychotropic medications Seroquel (an antipsychotic) for dementia with hallucination and agitation with a start date 10/19/23 and Bupropion (an antidepressant)…

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 4 of 5 residents (R29, R33, R35 and R69) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R29's face sheet, dated 3/13/24, indicated she was [AGE] years old. The immunization record, dated 3/13/24, indicated she received 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 initial and ongoing assessment of physical device equipment restricting independent movement for 1 of 1 resident (R35) reviewed for appropriate use of a reclining wheelchair. This has the potential to effect all residents that utilize reclining equipment. Findings include: R35's quarterly minimum data set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of non-Alzheimer's dementia, Parkinson's disease, restlessness, agitation, and frequent falls. R35's care plan dated 3/22/24, identified the ability to transfer with one to two staff assist, need for extensive assist of one staff for bed mobility and the ability to ambulate with one staff using a rolling walker or handheld assist. The care plan indicated the need for a high-backed wheelchair (w/c) and dependency on staff to reach intended destination. The care plan identified the risk for falls related to poor safety awareness, gait and balance problems 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.