The Estates At Excelsior LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interview the facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents (R27) reviewed for immunizations.Findings include:A Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Guidance, current at the time of survey, indicated individuals should receive recommended COVID-19 vaccinations, including booster doses, when eligible, unless medically contraindicated or refused. Long-term care facilities were responsible for assessing vaccination status and ensuring residents were offered recommended vaccines.R27's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and able to make needs known. R27's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), renal failure (decreased kidney function or kidney failure), diabetes…

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 offer a snack to residents on a routine basis when meals were greater than 14 hours apart. This had the potential to affect all 35 residents residing at the facility. Findings include: R187's 6/5/25, admission Minimum Data Set (MDS) assessment identified her cognition was intact and had no behaviors. R187 was independent with transfers, required assistance from staff with hygiene, and was occasionally incontinent of urine. She had diagnosis of heart failure, diabetes, and COPD. She was at risk for pressure ulcers and took insulin daily. Review of R187's baseline care plan identified she required assistance with bathing, dressing, hygiene, mobility, and transfers. Interview on 6/9/25 at 7:35 P.M., with R187 during the initial screen, she reported she had never been offered a snack during this stay or her last stay at the facility. She reported she was also not aware she could request a snack and stated, it would be nice to have a snack to get through the night. Interview on 6/9/25 at 7:40 p.m., 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 infection control practices were maintained in the kitchen when 1 of 1 staff were observed eating in the facility food preparation area. This had the ability to affect all 35 residents. Findings include: Observation on 6/11/25 at 7:28 a.m., of cook-A in the kitchen leaning over the food preparation counter near the microwave eating a sub sandwich. On the counter was a plate with food on it. Cook-A finished her sandwich, crumpled up a wrapper that said Subway on it and sat it on the hot holding steam table counter. Interview on 6/11/25 at 1:06 p.m., with the dietary manager identified staff should not be eating in the kitchen. Cook-A has some physical challenges, and the staff break room is located down a flight of stairs in the basement. He identified he has asked her in the past to at minimum step outside the kitchen door into the back hallway when she is eating her lunch. Interview on 6/11/25 at 1:26 p.m., with Cook-A identified she should not have been eating in the kitchen at a food prep counter. She reports she…

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

Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 35 residents. Findings include: Review of the QAPI meeting minutes from March 2025 through May 2025 that was provided, identified department heads were bringing data forth to QAPI on various topics such as; pressure injuries which was above national average, falls with trends identified, psychoactive medications, activities of daily living (ADL)'s assistance with a sharp increase in help needed, infection control with an upward trend of antibiotics identified, hospitalizations with 6 unplanned hospitalizations identified. There were no identified goals, no specific action plans of what the facility was going to do to make improvements, and no analysis of any data brought forward to the committee for the areas identified. Interview on 6/12/25 at 3:58 p.m., with administrator…

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 and document review, the facility failed to have evidence of a goal, an action plan, and analysis of data brought forth for the identified Performance Improvement Projects (PIP). This had the potential to affect all 35 residents residing at the facility. Findings include: Review of QAPI minutes provided from March 2025 through May 2025 identified the facility PIP plan for 2025 as follows: March 2025: 1) Call light response times, a trend had been identified. The facility was going to initiate call light audits, identify a root cause, and provide staff education. The director of nursing and nurse manager would provide oversight. There was no goal identified. 2) Notification of change in condition, identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee. 3) Enhanced barrier precaution identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, 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.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 3 of 3 sampled staff (housekeeping aide (HA)-A, speech therapist (ST)-A, and certified nursing assistant (NA)-A. This had the potential to affect all 35 residents. Findings include: Review of Employee Absence Report sheets from February through June 2025 identified the following areas of documentation: employee name, department, job title, symptom onset, illness reported, last shift worked, resolution date, return to work, specimen source, and treatment results. However, the facility did not accurately complete the logs to ensure all necessary information was monitored or identified how staff were cleared to return to work. Review of the February 2025, employee illness log identified: housekeeping aide (HA)-A was noted to have called in to work with symptoms of fever on 2/20/25. HA-A returned to work on 3/03/25. Review of February 2025 resident infection log identified 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.

Based on observation, interview, and document review, the facility failed to act promptly and provide resolution for resident concerns related to the dietary department failure to post upcoming menus. Findings include: Review of resident council minutes identified the following: 1.) January 2025, 4 residents attended the meeting, 2 residents voiced a concern that the menu was not posted, and the facility did not provide them to the residents. A Resident Council Departmental Response Form noting an identified issue: residents state the lunch and dinner menu was never posted, they never get a menu and when they ask the kitchen staff what the next meal is, they are often told food' or I don't know. The Response/Actions Taken: Due to cooler and freezer space we did not have the room to store all the ingredients on the menu. Moving forward we will be working with the director of nutrition to make ends meet. He was working with staff on better communication with the residents. Going forward the following weeks menus will be posted by the end of each week. The form was signed by 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 R27's 4/24/25, 14-day admission assessment, MDS identified her cognition was intact, and she required supervision to moderate assistance with activities of daily living, (ADLS). Her diagnosis list included ataxia, (impaired balanced or coordination), weakness, COPD, chronic back pain, and paranoid schizophrenia. R27's medical record identified MDS assessment: 1)4/8/25 entry tracking record 2) 4/13/25 discharge with return anticipated, with a 4/18/25 entry tracking record 3) 4/24/25 14-day admission assessment Review of R27's Hospital after visit summary identified she was hospitalized [DATE] through 4/18/25 with acute midline low back pain with right-sided sciatica, ((pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). R27's 4/13/25 at 10:35 p.m. progress note identified she had called 911 from her room with complaints of back pain. The ambulance arrived and she was transferred North Memorial hospital and admitted to acute care. Review of the transfer and 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.

Based on observation, interview, and document review, the facility failed to provide for Activities of Daily Living (ADL) related to assisting with toileting, turning and repositioning, queuing for food and hydration needs, and assisting with personal hygiene for 4 of 7 sampled dependent residents (R2, R7, R24, and R137). Findings include: R24 R24's 4/14/25 Significant Change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment, required extensive to total assistance with ADLs including toileting and personal hygiene. She was incontinent of both bowel and bladder and wore a disposable brief. R24 had diagnoses of a cerebral vascular accident (CVA-stroke), Post Traumatic Stress Disorder (PTSD), seasonal affective disorder, skin cancer oh her left thigh, hemiplegia of right dominant side (paralysis of one side of the body), depression, and aphasia (inability to speak), and malnutrition and had been admitted to hospice due to rapid decline. R24 required supervision for eating or touching assistant and staff needed to provide verbal queues as R24 completed 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.

Based on interview and document review the facility failed to ensure Notice of Medicare Non- Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) was given to the resident's representative for signature for 1 of 4 residents (R139) with known cognitive impairment. Findings include: R139's 4/15/25, discharge Minimum Data Set (MDS) assessment identified R139 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderately impaired cognition. R139's 1/17/25, baseline St. Louis University Mental Status Examination (SLUMS) assessment, a screening test for Alzheimer's disease and other forms of dementia. The therapist performed the SLUMS assessment with a score of 15 out of 30 which indicated dementia. A re-assessed SLUMS on 2/28/25, identified a lower score of 11 out of 30, indicating dementia. On 3/4/25, the discharge note from occupation therapy identified a SLUMS score remained at 11 out of 30. R139's, Notice of Medicare Non-Coverage identified services will end on 4/3/25. R139 signed the form on 3/22/25. R139's 1/27/25, care plan identified R139 was a vulnerable adult…

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.

R18's 4/9/25, quarterly Minimum Data Set (MDS) assessment identified R18's cognition was intact, R18 was dependent on staff for transfers and R18 attended dialysis. R18's care plan identified R18 had nutritional risk for malnutrition related chronic disease. R18 required increased protein related to end stage renal disease (ESRD), required a fluid restriction of 1200 milliliters (ml). R18 would receive supplements and be offered a liberalized diet. Staff were to communicate with renal dietician at dialysis, and explain and reinforce the importance of maintaining the diet ordered. The facility staff would provide and serve R18's diet as ordered, a modified renal, large portions, and a 1200 fluid restriction with snacks between meals three times a day. Observation and interview on 6/9/25 at 5:30 p.m., R18 was observed in his bed with his evening meal on the bedside table in front of him. R18 had roast beef with gravy over it, mashed potatoes with gravy, broccoli, grapes, a glass of milk, and a glass of apple juice. R18 said he was not supposed to get milk. He did not like apple juice,…

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 R7 R7's 3/26/25, quarterly Minimum Data Set (MDS) identified his cognition was intact, he felt down and depressed 2-6 days weekly, and had no behaviors. R7 required the use of a wheelchair, he was frequently incontinent of urine and occasionally incontinent of bm. He had diagnosis of seizures, anxiety, and depression, and received antipsychotics on a routine basis. R7's current care plan identified he had a diagnosis of major depressive disorder and generalized anxiety disorder. The focus was for R7 to remain stable and R7 to respond to interventions by staff to calm and redirect. the interventions were to complete assessments, redirect as needed, and provide emotional support. The care plan lacked any individualized target behaviors staff should be monitoring for. R7's June 2025, administration record identified he received risperidone 3 milligrams (mg) by mouth daily and aripiprazole 20 mg by mouth daily for major depressive disorder. The medical record lacked any identified target behavior that staff should…

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 and document review, the facility failed to complete a 48 hour baseline care plan upon admission for 1 of 10 residents (R187) reviewed. Findings include: R187's 6/5/25, admission Minimum Data Set (MDS) assessment identified her cognition was intact, she felt down and depressed 2 to 6 days weekly, and had no behaviors. R187 was independent with transfers, required assistance from staff with hygiene, and was occasionally incontinent of urine. She had diagnosis of heart failure, diabetes, COPD, respiratory failure, and atrial fibrillation. She was at risk for pressure ulcers, took insulin, and anticoagulant and a diuretic on a routing basis. Review of R187's baseline care plan identified she required assistance with bathing, dressing, hygiene, mobility, and transfers. The baseline care plan lacked mention of what level of assistance or the number of staff required to provide assistance. Interview on 6/11/25 at 2:15 p.m., with registered nurse (RN)-C identified she uses the care plan to identify how to provide care to a resident and how to determine how many staff are…

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 failed to develop and implement a comprehensive person-centered care plan for 1 of 2 sampled residents (R5) that addressed anticoagulant (prevents and breaks down blood clots) therapy with safety precautions. Findings include: R5's undated, current diagnoses list identified R5 had a transient ischemic attack (TIA) (blockage of blood flow to the brain that causes stroke-like symptoms) and cerebral infarction (reduce blood flow to a part of the brain that is obstructed by a blood clot). R5's 5/15/25, 5-day Minimum Data Set (MDS) identified R5 was moderately cognitive impaired and had no behaviors. R5 required staff set-up assistance with meals, supervision or touching assistance with dressing, transfers, and mobility. R5 had taken anti-platelets on a routine basis. R5's June 2025, medication administration record (MAR) identified clopidogrel bisulfate (Plavix) 75 milligrams (mg) daily (anti-platelet medication that prevents blood clot formation) for myocardial infarction (heart attack) on 5/13/25. R5's current, undated care plan lacked evidence of anti-platelet,…

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 and document review, the facility failed to revise the care plan to reflect current care needs for 2 of 13 sampled residents (R2 and R18) reviewed. Findings include: R2's 3/27/25, quarterly Minimum Data Set (MDS) assessment identified R2 had severe cognitive deficit. R2 had other behaviors 1-3 days. R2 was able to eat after set-up assistance but was dependent on staff for all other cares. R2 received a scheduled pain medication, an antipsychotic, anticoagulant, anticonvulsant, and diuretic. R2 had the diagnoses of cancer, high blood pressure, arthritis, stroke affecting the left side, dementia, depression and one-sided weakness. R2's 1/31/25, care plan identified she was on enhanced barrier precautions related to Foley catheter. R2 relied on extensive assist of 1-2 staff with her grooming and staff were to encourage her to participate as able. Observation on 6/10/25 at 9:58 a.m., of nursing assistant (NA)-B, NA-C, and NA-D who entered R2's room to provide morning cares. NA-D reported that it was easier to complete cares with 3 staff, but it could be done with 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.

Based on observation, interview and document review, the facility failed to identify appropriate turning and repositioning schedule based off professional standards of practice and document when staff performed repositioning for 1 of 2 residents (R32) who has a pressure ulcer and to minimize the risk of further pressure ulcer development and ensured interventions were implemented. Findings include: R32's current, undated diagnosis list identified R34 had a diagnoses of pressure ulcers, diabetes, and neurocognitive disorder with Lewy body dementia (dementia that causes a rapid decline in cognition and lack of physical function). R32's 5/22/25, admission Minimum Data Set (MDS) identified R34 was severely cognitively impaired. R32 had little interest or pleasure in doing things and trouble falling asleep never to 1 day, had felt down or depressed 12 to 14 days, felt tired, poor appetite 2 to 6 days. R32 was independent with eating, required substantial/maximal assistance with grooming, and supervision, and supervision or touching assistance with transfers. R32 was 5 feet (ft) and 3…

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 a prescribed therapeutic diet to 1 of 1 resident (R18) reviewed for dialysis. Findings include: R18's 4/9/25, quarterly Minimum Data Set (MDS) assessment identified R18's cognition was intact, R18 was dependent on staff for transfers and R18 attended dialysis. R18 had diagnoses of cystic fibrosis, severe protein-calorie malnutrition, immunodeficiency, lung transplant, fluid overload, end stage renal disease, renal dialysis, and diabetes. Observation and interview on 6/9/25 at 5:30 p.m., R18 was observed in his bed with his evening meal on bedside table next to him. R18 had roast beef with gravy over it, mashed potatoes with gravy, broccoli, grapes, a glass of milk, and a glass of apple juice. R18 said he was not supposed to get milk. He did not like apple juice, potatoes, or broccoli and it was right here on his diet slip, but they send it anyway. Staff returned to R18's room and placed a bottle of Nepro supplement on his bedside…

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 implement their dialysis contract and arrange for transportation to dialysis for 1 of 1 resident (R18) who missed their regularly scheduled ride service for dialysis treatment. Findings include: R18' s 4/9/25, quarterly Minimum Data Set (MDS) assessment identified R18's cognition was intact, R18 was dependent on staff for transfers and R18 attended dialysis. R18's care plan identified R18 was a vulnerable adult with decreased physical abilities. R18 has difficulty being mobile on his own. Staff were to encourage R18 to go for his scheduled dialysis appointments. Metro mobility picked up at 11:30 a.m., with a return ride at 5:15 p.m. R18's anxiety makes communication difficult at times when delivering information. R18 had alternation in mobility and required assistance in and out of his bed with a mechanical stand lift and 2 staff. Interview on 6/9/25 at 1:26 p.m., with R20 the roommate of R18, identified that R18 was supposed to get up for dialysis…

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 and document review, the facility failed to ensure supply and administration of ordered medications for 1 of 1 resident (R24) reviewed for pharmacy services. Findings include: R24's current, undated face sheet identified R24 had a diagnosis of diabetes mellitus type 2, neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems), and neurogenic bowel (lack of bowel control due to nerve problems). R24's 4/14/25, Significant Change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and was dependent on staff for activities of daily living (ADL's). R24 was admitted to Hospice services with a terminal diagnosis of CVA, weight loss, and decline in physical condition. R24's 12/06/24, hospital discharge summary identified R24 presented to the local hospital with abdominal pain, nausea, vomiting, diarrhea and low blood pressure on 12/02/24. R24's imaging of the abdomen/pelvis identified acute diarrheal illness and was positive for clostridium difficile (C-Diff) (bacteria in the gut that causes…

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 offer an alternative food item for 1 of 1 residents (R187). Findings include: Observation on 6/11/25 at 8:02 a.m., of nursing assistant (NA)-A passing room trays identified he removed a tray from the cart and entered R187's room, placed the tray on the overbed table in front of her and removed the cover. Her plate had 1 egg and 2 slices of toast. R187 picked up the toast and said to NA-A I don't eat toast, now what am I supposed to eat? NA-A did not respond, he left the room, passed the remainder of the room trays, then went to assist another resident with her meal. NA-A never returned to R187's room to offer an alternative and did not notify the kitchen that she had received food she would not or could not eat. Interview on 6/11/25 at 8:53 a.m., with NA-A confirmed he heard R187 say she did not eat toast but said because he was the only one passing trays, he did not have time to tell the kitchen. He reports when someone doesn't like what is served, he offers a snack like Jello. He identified he was not…

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

Based on interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 (R24 and R238) sampled residents reviewed for antibiotic stewardship. Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the resident current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out [ATO]. Review of Monthly Infection…

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 1 of 5 (R5) were offered and/or provided updated vaccination for pneumococcal disease, in accordance with Centers for Disease Control (CDC). Findings include: Review of the current, 10/26/24, Centers for Disease Control (CDC) Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV21) at any age and a PPSV23 at or after the age of [AGE] years old. R5 was admitted [DATE]. R5's, 5/16/25, 5-day Minimum Data Set (MDS) identified R5 was [AGE] years old and had a diagnosis of non-[NAME] (blood cancer) lymphoma, anemia, and dementia. R5 had received PPSV-23 on 2/26/16 and PCV-13 on 4/15/19. Section O-Special Treatments and Programs…

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 implement the use of an air pressure redistribution mattress to aid in providing pressure ulcer relief for 1 of 3 residents (R1) reviewed for pain management. Findings include: R1's Face Sheet undated indicated R1 had the following diagnoses: hospice, history of cerebral infarction (stroke), peripheral vascular disease, adult failure to thrive and abnormal weight loss. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had moderate cognitive impairment, was dependent on staff for all activities of daily living (ADLs), required ongoing pain management and received hospice services. R1's care plan initiated 12/9/24 indicated R2 had an alteration in skin integrity related to peripheral vascular disease, adult failure to thrive, anorexia, and cerebral infarction (stroke). Interventions included pressure redistribution mattress to bed. R1's Wound Care note dated 12/3/24 indicated R1 was being seen for the evaluation and treatment…

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

Based on observation, interview, and document review, the facility failed to implement appropriate personal protective equipment (PPE) to prevent the spread of infection for 1 of 1 residents (R2) observed for enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted masks, gown and glove use during high contact resident care activities). Findings include: Review of Centers for Disease Control and Prevention(CDC) guidance dated 4/2/24 Implementation of PPE Use in Nursing Homes to Prevent Spread of Multi drug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for EBP included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. Guidance also included EBP may be indicated (when Contact Precautions do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: R1's admission Record dated 9/27/24 indicated R1's diagnoses included diabetic foot ulcers and non-pressure chronic ulcer of right heel and midfoot. R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition. R1's care plan dated 9/30/24, indicated R1 had a right great toe wound with staff interventions to evaluate the wound, noting any possible complications such as an increase in drainage from the wound, odor, color, or consistency, to notify the provider immediately. On 10/22/24, nurse practitioner (NP)-A was onsite assessing R1's diabetic foot ulcer. NP-A wrote orders for an Xray and white blood cell (WBC) count lab to rule out osteomyelitis (infection of the bone) due to the diabetic foot ulcer deteriorating. On 10/22/24 at 2:37 p.m., a progress note indicated R1 was sent home 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 interview and document review, the facility failed to ensure the Quality Assurance Process Improvement (QAPI) committee was effective in maintaining appropriate action plans to correct a quality deficiency identified during a previous survey related to infection control practices for indwelling foley catheters which resulted in a deficiency identified during this survey: Findings include: The Facility Assessment Tool dated 4/12/24, indicated under the heading, Part 2: Services and Care We Offer Based on our Residents' Needs bowel and bladder toileting programs, incontinence prevention and care, intermittent or indwelling urinary catheter, ostomy, colostomy, responding to requests for assistance to the bathroom, toilet promptly to maintain continence and promote resident dignity. Further, infection prevention and control and identification and containment of infections, prevention of infections. The facility QAPI plan for 2024, identified five goals that included: • work to improve the new hire orientation and training process to increase retention. • work to improve…

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 insulin pens were appropriately labeled according to manufacturer's guidelines with an opened date in 1 of 2 medication carts(North) for 2 of 2 residents (R20, R22) whom required use of an insulin pen. In addition, the facility failed to ensure three bottles of eye drops were appropriately labeled with an open date to prevent expired eye drops from being administered. This deficient practice affected 1 of 2 medication carts reviewed for storage and 5 of 5 residents (R1, R12, R20, R22 and a previously discharged resident) reviewed for medication administration. Findings include: Observation on 5/14/24 at 08:56 a.m., of the north medication cart was reviewed with registered nurse (RN)-A. A single opened Humulin 70/30 insulin pen labeled for R22, and a single opened NPH insulin pen labeled for R20 were inside the top left drawer of the medication cart. Both pens had visible insulin removed (administered) ; however, neither label had anything to identify when the pens had been removed from 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 document review, the facility failed to ensure proper hand hygiene during wound cares for 1 of 1 resident (R15), failed to ensure proper personal protective equipment (PPE) for 2 of 2 residents (R331, R5), and failed to ensure proper placement of foley catheter bag and cleaning with catheter cares for 1 of 1 resident (R4) reviewed for infection control. Findings include: R331's Optional State Assessment (OSA) dated 5/7/24, indicated intact cognition, did not have behaviors or reject cares, required extensive assist with transfers, bed mobility and toileting, had cerebral palsy, hemiplegia (paralysis affecting one side of the body) or hemiparesis (one sided muscle weakness), and had a surgical wound. R331's physician orders indicated the following orders: 5/2/24, staff to follow enhanced barrier precautions. 5/8/24, venous ulcer right posterior calf: cleanse wound with wound cleanser and pat dry; apply skin prep around wound, cover with Adaptic, secure with an ABD and Kerlix…

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 provide a written notification/copy of a bed hold for 2 of 2 (R1, R20) residents reviewed for hospitalization. Findings include: R1's face sheet dated 5/16/2024, listed the following diagnoses: dysphagia (difficulty speaking), obesity, syncope (fainting-dizziness), hypotension (low blood pressure), chronic pain syndrome, hyponatremia (low salt levels), diabetes mellitus type two (DM), hypertension (HTN-high blood pressure), and chronic obstructive pulmonary disease (COPD-disease that difficulty breathing). Progress notes indicated R1 went to an emergency department on 10/4/23, and was hospitalized two times on the following dates: -9/2/23 thru 9/7/23 -9/19/23 thru 9/23/23 R1's medical record lacked evidence a written notification of the bed hold policy was provided to R1 or their representative prior to or during the hospitalization. R20's face sheet dated 5/16/24, listed the following diagnoses: immunodeficiency, malnutrition, weakness, shortness 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 1 of 5 resident (R5) were offered or received pneumococcal vaccination in accordance to Center for Disease Control (CDC) recommendations. Findings include: The CDC Pneumococcal Vaccine Timing for Adults undated, indicated adults aged 65 years and older who have had no prior pneumococcal vaccinations could either have option A which indicated PCV20, or option B, give PCV15 and follow with PPSV23 after at least one year of giving PCV15. If only the PPSV23 vaccination was administered prior at any age, option A indicated PCV20 could be administered after 1 year or option B indicated PCV15 could be administered after 1 year. If only the PCV13 vaccination was administered at any age, option A indicated PCV20 could be administered after 1 year, or PPSV23. If PCV13 was administered at any age, and PPSV23 was administered prior to [AGE] years of age, option A indicated PCV20 could be administered after five years, or option B indicated PPSV23 could 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an allegation of staff to resident abuse was reported immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated R1 was mildly cognitively impaired. R1's care plan dated 4/25/24 indicated R1 required the assist of one for transfers. A facility Nursing Home Incident Report (NHIR) to the SA dated 4/23/24 indicated the report was submitted on 4/22/24 at 12:15 p.m. The report indicated R1 stated a nursing assistant grabbed her by the rib cage, picked her up and threw her onto the wheelchair to get to the bathroom and then back to bed during the evening of 4/20/24. R1 stated the nursing assistant was mean, aggressive, forceful and, rough. On 4/25/24 at 9:58 a.m., R1's son was interviewed and stated R1 described the incident as being manhandled and was feeling pain. On 4/25/24 at 10:21 a.m., R1 stated that 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 interview, observation and document review, the facility failed to ensure timely resolution of missing personal property for 3 of 3 residents reviewed (R1, R5, and R7) for resident rights. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], showed an admission date of 6/30/23, with diagnoses including stroke, and paralysis on one side of body. The MDS indicated R1's intact cognition. R5's admission MDS dated [DATE], showed an admission date of 6/27/23, diagnoses including septicemia, urinary tract infection, and depression. The MDS indicated that R5 has moderate cognitive impairment. R7's annual MDS dated [DATE], showed diagnoses including dementia, anxiety disorder, and depression. The MDS indicated R7 has moderate cognitive impairment. During interview on 8/8/23 at 3:15 p.m., R1 stated he was admitted to the facility on [DATE] and brought in some clothes that went missing for more than a month now. R1 stated he was told these might be downstairs but that he could not go there to find…

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 interviews and documents review, the facility did not ensure participation in care planning for 1 of 5 residents (R1) whose input preferences were not reflected in the care plan. In addition, the facility did not ensure completion of care plan by all members of the interdisciplinary team (IDT) and the facility did not ensure residents understood and acknowledged the care plan for 5 of 5 residents (R1, R2, R3, R4, and R5) reviewed for care plan. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated an admission date of 6/30/23. The MDS listed R1's active diagnoses including stroke, paralysis on one side of the body, depression with intact cognition. The MDS also indicated R1 needed extensive assistance with one-person physical assistance for personal hygiene and dressing, and R1 was totally dependent on staff for bathing. R1's care plan identified focus areas that include the following: - Self-care deficit related to hemiplegia (paralysis on one side of the body). 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 interview, observation and document review, the facility failed to ensure resident call device was within reach and resident preference was respected for 1 of 3 residents (R2) observed for dignity. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition. The MDS also indicated that R2 required extensive assistance with 2-person physical assistance for bed mobility, transfers, ambulation, and personal hygiene, and total dependence on staff for toilet use. R2's care plan identified self-care deficit related to fracture and schizoaffective disorder. The plan of actions included staff to help with transfers, ambulation, toilet use, bathing, dressing, and personal hygiene. On 8/8/23 from 1:55 p.m. to 2:34 p.m., R2's call button was observed lying on the floor and not within R2's reach. R2 stated she would call staff when she needed to use the bathroom. R2 stated, it takes a long time for staff to respond to her calls. R2 was unable to give a specific length of response time for call…

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 administer dietary supplements recommenced for 1 of 1 (R1) who was comprehensively assessed upon admission and received a recommendation to received nutritional supplements two times daily. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated an admission date of 6/30/23, with intact cognition. R1's care plan identified focus areas that included the following: - Potential for nutritional problem related to acute ischemic stroke as evidenced by weight loss prior to admission greater than 10 lbs. The interventions include monitoring for signs of malnutrition such as muscle wasting, significant weight loss of 3 pounds (lbs) in 1 week, above 5% in 1 month, above 7.5 % in 3 months, or above 10% in 6 months, obtaining weight per policy/order, and providing nutritional supplements 4 ounces two times a day with breakfast and lunch. Review of progress notes indicated: Progress notes: -8/7/2023, 12:50 p.m. Dietary Writer…

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.