The Emeralds At Fairbault LLC

Based on interview and document review, the facility failed to identify and protect all residents at risk of financial exploitation during investigations into 4 of 4 residents (R1, R2, R3, R4) reviewed who made allegations of financial exploitation. This had the potential to affect all 67 other residents who were residing in the facility, including R5, whose representative subsequently identified and reported additional allegations of financial exploitation. Findings include:Untitled resident questionnaire documents dated 6/17/25 and 6/18/25, included dates, resident names, interviewer signatures, and three questions. Questions included: have you noticed any unusual transactions on your bank account recently; Have you noticed any missing valuables, money, checks, credit cards or debit cards recently; and do you know how to report facility concerns, lost, missing, or damaged items. Questionnaires were completed for 29 residents. One questionnaire had a resident name written down and crossed out with no further information, and one questionnaire had a resident name, R5, date 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.

Based on observation, interview, and document review, the facility failed to ensure the three-compartment dish sink was of proper sanitization parts per million (ppm) which had the potential to affect all 76 residents who received meals from the main kitchen. Furthermore, the facility failed ensure employees wore beard restraints to prevent hair from contacting food. Findings Include: A report titled Diet/consistency Rollup printed on 4/30/25, categorized each diet and had total meals served out of the main kitchen as 76. During the initial kitchen walk through conducted on 4/28/25 at 1:22 p.m., an area over the three-compartment sink had logs for documentation of water sanitization for April 2025, completed for April 1-24th. Above the sink were two large bottles held by a wire rack with two tubes that ran down into the three compartment sink, both were empty. The bottle on the left was labeled quaternary sanitizer and the one on the right was labeled pot/pan detergent and sanitizer. A large bottle of Dawn dishwashing detergent sat on the far right of the three-compartment sink. 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.

Based on observation, interview, and document review, the facility failed to ensure soiled personal laundry and linens were bagged (i.e., contained) at the point-of-use and transported in a manner to reduce the risk of cross-contamination and potential infectious spread in 1 of 1 main washrooms and 2 of 2 units (70's, 90's) reviewed. This had potential to affect all 75 residents within the care center. Findings include: On 4/29/25 at 7:57 a.m., the campus' main laundry washroom was toured with housekeeper (HSK)-A present. HSK-A explained they were the primary person who completed laundry for the care center, and they then provided a tour of the laundry process and the machines used. The soiled linen receiving area and washroom were located on one side of the hallway and folding area (clean) on the opposite. However, in the hallway between these areas were a series of mobile, off-white colored hard plastic bins including one labeled, Soiled Linen Only, in black paint. The bin was covered with a light-blue colored cloth covering which was lifted exposing it's contents which was soiled…

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 dignity was maintained for 2 of 2 residents (R54, R74) who utilized urinary catheters. Findings include: R54 R54's annual Minimum Data Set (MDS) dated [DATE] identified R54 with intact cognition, impairment of both lower extremities, dependent on staff for toileting hygiene and lower body dressing and had an indwelling catheter (tube for urine collection from bladder to a bag outside of the body). During observation on 4/28/25 at 1:42 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of bed visible to the hallway. During observation on 4/28/25 at 2:39 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of bed visible to the hallway. Two staff walked past the room. At 5:13 p.m., a staff member pushed a meal cart past R74's room. At 5:15 p.m., one staff member was observed inside the room speaking to R74 and left the room. During observation and interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R40) whose tube feeding pole and equipment had dried, white substance on it. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 with intact cognition and diagnoses of depression, anxiety, chronic respiratory failure resulting in oxygen dependence, and a history of head and neck cancer with all nutrition through a percutaneous endoscopic gastrostomy (PEG) tube (soft flexible feeding tube inserted through the abdominal wall into the stomach). During observation on 4/28/25 at 5:07 p.m., R40's tube feeding (TF) pole was coated with dried white substance on entire surface of the pole and all five legs of the base. The TF unit/machine had greasy smeared substance on the entire front programming screen. During interview with licensed practical nurse (LPN)-A on 4/29/25 at 1:03 p.m., LPN-A stated the nursing staff was responsible for wiping down…

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 grievances were sufficiently acted upon for 1 of 1 resident (R53) reviewed for grievances. Findings Include: R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 was cognitively intact. During an interview on 4/28/25 at 4:28 p.m., R53 stated approximately two months ago, during an evening shift a nursing assistant entered her room and attempted to change an incontinent brief. R53 was concerned because she didn't wear incontinent briefs, and the aid was unkind during the encounter. The following morning R53 reported the incident to staff. During a subsequent interview on 4/29/25 at 1:28 p.m., R53 stated she filed a grievance approximately two months ago and requested the nursing assistant not return to the unit. R53 confirmed that no one from the facility followed up with the results of the grievance. R53 stated the aid did work on the unit after staff was made aware of the incident and told residents he had been off…

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

Based on interview, observation, and documentation review, the facility failed to ensure a comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 1 resident (R51) reviewed for smoking. Findings include: R51's admission Minimum Data Set (MDS) assessment, dated 2/19/25, indicated R51 had intact cognition with no hallucinations or delusions present and no behaviors. Section J: Health Conditions indicated R51 currently used tobacco. Section O: Special Treatments and Programs indicated R51 used oxygen. R51's admission Record, printed 5/1/25, identified R51's admission date to the facility as 2/13/25. Furthermore, it identified the following relevant diagnoses: nicotine dependence, emphysema (chronic lung disease that progressively damages the tiny air sacs in the lungs), and congestive heart failure (condition where the heart doesn't pump blood as efficiently as it should). During an interview on 4/28/25 at 6:54 p.m., R51 stated she smoked cigarettes. R51 stated she had smoked for a long time. R51 stated the facility assessed me to make sure…

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 ensure the care plan was updated and revised to reflect current interventions for 1 of 1 resident (R62) reviewed for positioning and mobility. Findings include: R62's quarterly Minimum Data Set (MDS) dated [DATE], identified R62 as independent with mobility, had no upper extremity impairment (shoulder, elbow, wrist, hand), and used a walker. R62's Occupational Therapy Discharge summary dated for services March 12, 2025, through April 9, 2025, indicated therapy was provided seven times for muscle weakness. R62's therapy involved improved strength for the left wrist, and R62 was given a brace on 4/9/25. Therapy directed R62 to wear the brace as tolerated. R62's care plan with a review date of 3/17/25, indicated a walking program of 200 feet one to three times per day with an assist of one during ambulation, bed movements, and transfers. The care plan lacked updates after R62 was discharged from therapy to walk independently with his walker…

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 reassess a resident with known constipation to determine what, if any, new interventions could be put in place to prevent constipation for one of one resident (R28) reviewed for constipation. Findings include: R28's quarterly Minimum Data Set (MDS), dated [DATE], indicated R28 was cognitively intact, was frequently incontinent of bowel without a bowel program, and required substantial to maximum assistance with toileting. R28's diagnoses, dated 3/7/25, indicated R28 had several medical diagnoses including Parkinson's Disease in which constipation is a common symptom. R28's bowel movements document in April indicated R28 often went three or more days in between bowel movements. R28's first documented bowel movement in April was 4/10/25, indicating 10 days without a bowel movement. R28 also did not have a bowel movement between 4/17/25 and 4/20/25 indicating three days between bowel movements, between 4/20/25 and 4/26/25 indicating 6 days between bowel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow-up and implement treatment for improved hearing for 1 of 1 resident (R62) who had complaints of hearing loss which were not addressed. Findings include: R62's admission Minimum Data Set (MDS) dated [DATE], identified R62 as highly impaired with the absence of useful hearing, did not wear hearing aids, and had a diagnosis of unspecified sensorineural hearing loss. R62's care plan initiated 9/23/24, indicated the use of a pocket talker to aid in communication, but failed to mention the use of R62's hearing aids. R62's most recent care plan with a review date of 3/24/25 indicated sensorineural hearing loss bilaterally. The care plan indicated the use of a pocket talker to aid in communication as needed and to speak clearly and distinctly to the resident, but failed to mention R62's hearing aids. R62's physician's note dated 12/12/24, indicated R62 wore hearing aids. R62's quarterly Minimum Data Set (MDS) dated [DATE], identified R62…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively reassess and, if needed, determine or develop proactive interventions to help address pressure injury risk and development after a new pressure injury was identified (i.e., change of condition) for 1 of 2 residents (R13) reviewed whom had active pressure injuries. Findings include: The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 2/2023, identified definitions for pressure ulcer care and treatment. This included guidance provided on the several stages of injury definition which included, Stage 3 Pressure Ulcer: Full-thickness skin loss . subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible . depth of tissue damage varies by anatomical location . Undermining and tunneling may occur . R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had intact cognition along with multiple…

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 record review, the facility failed to provide services to maintain and/or prevent loss of range of motion and contracture care for 1 of 1 residents (R51) reviewed for limited range of motion. Findings include: R51's admission Minimum Data Set (MDS) assessment, dated 2/19/25, indicated R51 had intact cognition with no hallucinations, delusions, behaviors or rejection of care. In addition, R51 had no impairment in function limitation in range of motion, utilized a wheelchair for mobility, dependent on staff for lower body dressing and dependent on staff for transfers. R51's admission Record, printed 5/1/25, indicated the following relevant diagnoses: chronic pain, abnormalities of gait and mobility, dorsalgia (back pain), muscle weakness, disease of spinal cord, restless sleep syndrome and cervicalgia (neck pain). During an interview on 4/28/25 at 6:51 p.m., R51 stated she was not getting physical therapy (PT). R51 stated she had been getting occupational therapy (OT) but hadn't received any OT in probably at least two weeks. R51 expressed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a resident with a catheter had medical justification for continued use and failed to attempt a trial removal, if recommended, for one of one resident (R35) reviewed for indwelling catheter. Findings include: R35's quarterly Minimum Data Set (MDS), dated [DATE], indicated R35 had moderate cognitive impairment, required supervision with toileting and moderate assistance with bathing and had an indwelling catheter in place. R35's admission MDS, dated [DATE], indicated R35 was admitted with an indwelling catheter in place. R35's Diagnoses, dated 5/16/22, indicated R35 had several medical diagnoses related to potential need for an indwelling catheter including other obstructive and reflex uropathy which can hinder the normal flow or urine, unspecified retention of urine, renal hypoplasia (a congenital condition in which one or both kidneys are underdeveloped), benign prostatic hyperplasia with and without lower urinary tract symptoms (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 interview, observation and document review the facility failed to comprehensively reassess a resident for pain who was hospitalized for concerns with her pain medication and had pain medication changes, and who still reported frequent pain for one of one resident (R1) reviewed for pain. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact and independent with most activities of daily living (ADLs). The MDS further indicated during the look back period R1 received scheduled pain medication, no PRN (as needed) pain medications, and was in pain almost constantly which effected R1's sleep and day to day activities. R1's Orders indicated R1 had several medications for pain including: Buprenorphine HCl Sublingual Tablet Sublingual, give 2 milligrams (mg) sublingually one time a day for chronic pain syndrome, dated 4/11/25; Oxycodone HCl Oral Tablet 5 mg, give 1 tablet by mouth every 6 hours as needed for Chronic pain/Nonacute pain and give 2 tablets by…

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 immediately assess a resident after a change in condition for one of one resident (R1). License practical nurse (LPN)-A noticed a change in condition at 8:00 a.m. on 3/4/25, started taking vital signs at 10:30 a.m., and emergency medical services (EMS) was not called until 11:33 a.m. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis with hematuria. R1's additional diagnoses included chronic obstructive pulmonary disease, acute kidney failure, hallucinations, chronic respiratory failure, dependence on supplemental oxygen, and chronic obstructive pulmonary disease with exacerbation. R1 was discharged from the facility on 3/4/25. R1's admission hospital medical records indicated R1 was admitted to the hospital from [DATE] to 2/25/25 due to covid-19, urinary tract infection, and encephalopathy. It was noted during her admission that her skin was warm and dry. No skin concerns…

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 obtain an order for oxygen for one of seven residents (R1) who was on continuous oxygen. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis with hematuria. R1's additional diagnoses included chronic obstructive pulmonary disease, covid-19, chronic respiratory failure, dependence on supplemental oxygen, chronic obstructive pulmonary disease with exacerbation, and obstructive sleep apnea. R1 was discharged from the facility on 3/4/25. R1's admission hospital medical records indicated R1 was admitted to the hospital from [DATE] to 2/25/25 due to covid-19, urinary tract infection, and encephalopathy. R1 was to resume home regimen including oxygen as needed to keep oxygen saturation from eighty-eight percent to ninety-four percent. R1 was on two liters of oxygen via nasal cannula. R1's progress note dated 2/25/25, indicated R1 was admitted to the facility and used two liters 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 failed to ensure allegation of a potential drug diversion was recognized and reported to the state agency (SA), reviewed for misappropriation of property. Finding s included: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitive and had a diagnosis of narcolepsy (a rare neurological condition that makes people very sleepy during the day and can cause them to fall asleep suddenly). R1's order summary dated 1/6/25, identified an order for methylphenidate long acting (LA) (a stimulant medication to help with narcolepsy) 20 mg capsule to be given every day in the morning for narcolepsy. R1's Medication Administration Record (MAR) dated 1/6/25, identified R1 did not receive methylphenidate extended release (ER) 20 mg capsule as indicated by the number, 5 documented that indicated to see progress note. It was documented from 1/6/25 to 1/20/25, that R1 received his methylphenidate daily as indicated by nurse initials. R1's progress…

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 put a protection plan in place and thoroughly investigate an allegation of drug diversion for 1 of 1 resident (R1), reviewed for misappropriation of property. Finding s included: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitive and had a diagnosis of narcolepsy (a rare neurological condition that makes people very sleepy during the day and can cause them to fall asleep suddenly). R1's order summary dated 1/6/25, identified an order for methylphenidate long acting (LA) (a stimulant medication to help with narcolepsy) 20 mg capsule to be given every day in the morning for narcolepsy. R1's Medication Administration Record (MAR) dated 1/6/25, identified R1 did not receive methylphenidate extended release (ER) 20 mg capsule as indicated by the number, 5 documented that indicated to see progress note. It was documented from 1/6/25 to 1/20/25, that R1 received his methylphenidate daily as indicated by nurse…

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 necessary coordination of services between the facility and the hospice agency for 1 of 3 residents (R2) reviewed for hospice services. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated intact cognition with diagnoses of cancer, malnutrition, and depression. R1 required moderate assist with transfers and maximal assist with toileting, bathing, and dressing. R1 was at risk for pressure ulcers but had not pressure ulcers. R1 had pressure relieving device in bed and chair and received medication or ointment to skin. R1 was on hospice. On 10/17/24 at 4:00 p.m., R1's medical record lacked current medication list with a list of medication-specific hospice covered medications, a care plan, goals for care, hospice certification, the hospice election form, hospice aide visits and hospice orders. During an interview on 10/17/24, hospice RN (HRN-A), stated the hospice was handling R1's pressure issues and had not been…

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 report an allegation of sexual abuse immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's admission Record dated 6/17/24, indicated R1's diagnoses included pain in left shoulder, weakness, history of falling and chronic kidney disease. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 required extensive assistance with activities of daily living (ADLs) and had intact cognition. R1's care plan dated 6/17/24 indicated R1 was at risk for abuse with interventions including staff to follow facility vulnerable adult policies and procedures, and the State Agency will be notified of any suspected abuse. On 9/4/24 at 12:21 a.m. R1 stated he was sexually abused on 8/23/24 when a female nurse touched his penis inappropriately after putting a cream on his left hip. He was pissed off and not happy about the situation. He requested the nurse manager in his room and told him about…

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 sexual abuse was thoroughly investigated and adequate resident protection provided to ensure safety for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's admission Record dated 6/17/24, indicated R1's diagnoses included pain in left shoulder, weakness, history of falling and chronic kidney disease. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 required extensive assistance with activities of daily living (ADLs) and had intact cognition. R1's care plan dated 6/17/24 indicated R1 was at risk for abuse with instruction to staff to follow facility vulnerable adult policies and procedures. R1's medical record lacked evidence of the incident being investigated. On 9/4/24 at 12:21 a.m. R1 stated he was sexually abused on 8/23/24 when a female nurse touched his penis inappropriately after putting a cream on his left hip. He was pissed off and not happy about the situation. He requested the nurse…

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 1 of 1 resident (R5) who was observed to have medications in his room, had been appropriately assessed and deemed safe to self-administer medications. Findings include: R5's admission record, indicated history of a heart disease, morbid obesity and type 2 diabetes. R5's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R5 was cognitively intact, had clear speech, could understand and be understood. R5 was dependent upon staff for most activities of daily living other than set up for eating and oral hygiene. R5's June medication administration record (MAR) and treatment administration record (TAR) indicated 9:00 a.m. oral medication orders: 1. Cardizem CD capsule extended release 24-hour 120 milligram (mg) Give 1 capsule by mouth one time a day, dated 9/25/23. 2. Digox oral tablet 125 microgram (mcg) give 0.125 mg by mouth one time a day. Dated 9/25/23. 3. Losartan Potassium oral tablet 50 mg. Give 1 tablet by mouth…

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 follow the standards of practice for the: (1) administration of nebulizer treatment solution and do the necessary assessment during and after the administration of the nebulizer treatment solution; and (2) failure to follow physician order to apply compression stockings daily for one of one resident (R8) observed for medication administration. Findings Include: R8's admission record indicated R8 had a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and history of pulmonary embolism. R8's admission Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact, had clear speech and was able to understand and be understood. MDS also indicated R8 had not exhibited rejection of cares. Resident's care plan for activities of daily living (ADL's) dated 6/18/24, indicated intervention of resident is able to put compression stockings on with help of a sock aide. R8's medication administration…

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, record review and observation, the facility failed to provide pharmacy services for 1 of 1 resident (R6), who did not receive her scheduled medication for pain resulting in uncontrolled pain and the use of narcotic pain medication. Furthermore, the facility failed to follow safeguards to ensure residents received the correct medications for 1 of 1 resident (R6). R6's admission record indicated R6 had a history of perforation of the intestine, encounter for surgery on the digestive system, gastrostomy status and colostomy status. R6's admission Minimum Data Set (MDS) dated [DATE], indicated she was unable to complete the cognitive assessment and was sometimes understood and sometimes able to understand. MDS also indicated R6 to have pain and used as needed pain medication (PRN) in the last 5 days. R6's medication administration record (MAR) dated June 2024, indicated she was supposed to receive acetaminophen 1000 milligrams (mg) every 6 hours via percutaneous endoscopic gastrostomy (PEG) tube,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a provider order for a urine analysis with urine culture (UA/UC) and sensitivity had been obtained in a timely manner for 1 of 1 resident (R7) reviewed for change of condition. Findings include: R7's admission record indicated a history of hemiplegia and hemiparesis following cerebral infarction, and chronic kidney disease. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact, had clear speech and was understood and able to understand others. R7's provider order dated 6/13/24, indicated R7 required a UA/UC with sensitivity related to diagnosis of dysuria. R7's medication administration record (MAR) and treatment administration record dated 6/2024 indicated an order for UA/UC had been put in on 6/14/24 and had check marks with initials noted for the evening and night shift for 6/14, 6/15, 6/16, and 6/17. No documentation noted for the day shift. Leaving open holes on the day shifts. R7 progress note date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine bathing and personal hygiene needs were addressed and completed for 3 of 5 residents (R47, R69, R31) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R47's quarterly Minimum Data Set (MDS), dated [DATE], identified R47 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS outlined R47's care plan, dated 11/21/23, identified R47 had a self-care deficit due to a mobility decline and listed a goal for R47 to accept assistance with all self cares. The care plan including several interventions to help meet this goal including, Bathing Preferences: Tub bath or shower, day or evening, once weekly. Further, the care plan outlined R47 needed assistance with dressing and personal hygiene needs. On 2/5/24 at 2:08 p.m., R47 was interviewed about their care at the facility and she expressed frustration as they hadn't…

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 1 of 5 medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect all 13 residents that resided on the second floor of the facility. Findings include: Electronic communication (email) from the assigned Ombudsman (official/advocate appointed by the Minnesota Board on Aging) for the facility on 2/2/24 stated, Of note, I did observed a RN station that was unattended; unlocked med drawers and confidential information displayed on a pc [personal computer] screen. During observation and interview on 2/5/24 at 5:25 p.m., licensed practical nurse (LPN)-A walked away from second floor medication cart with pills in a medication cup and entered a resident room at the end of the hall. The medication cart was unlocked and laptop left open with patient identifying information visible to the 5 residents seated in the dining room eating their dinner. During interview, LPN-A stated the open…

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 dignity was maintained for 1 of 1 residents (R20) who utilized a urinary catheter. Findings include: R20 quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of malnutrition, coronary artery disease (narrowing of blood vessels supplying the heart), hypertension, obstructive uropathy (difficulity fully voiding), depression and chronic obstructive pulmonary disease. In addition, R20 was documented requiring an indwelling catheter. R20's care plan dated 8/11/23, indicated, Foley catheter care per policy. During observation and interview on 2/5/24 at 2:09 p.m., R20 was laying in bed with a large urinary catheter bag attached to bed frame facing the hallway. No privacy bag was noted on the bed or on the wheelchair. R20 stated the facility did not offer or provide a cover for his catheter drainage bag while in his bedroom or out in the facility's hallway. During interview with registered nurse (RN)-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 interview and document review, the facility failed to ensure resident and/or resident representatives participated in the resident care planning process and subsequent development of interventions for 2 of 2 residents (R53, R74) reviewed for participation in care planning. Findings include: R53 R53's admission Minimum Data Set (MDS) dated [DATE], indicated that R53's Brief Interview for Mental Status was left blank. The MDS indicated that R53's short- and long-term memory were ok and R53 was independent with decision making. The MDS indicated that R53 was diagnosed with diabetes, a heart dysrhythmia (irregular heart rhythm), a stroke, and a seizure disorder. R53's Care Conference Form dated 1/9/24, indicated the form was completed for R53's admission care conference and included blank sections for medication assessment, physical restraints, fall risk, positioning, exams (dental and eye, bowel, bladder/bladder and bathing, immunizations, IDT (interdisciplinary team) care conference summary, nurse…

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 assess a resident for the ability to self-administer medications with an albuterol inhaler bedside for one of one residents (R43) reviewed for self-administration of medications. Finding include: R43's quarterly Minimum Data Set, dated [DATE], indicated R43 was admitted to the facility on [DATE] and was cognitively intact. R43's Physician Orders, dated 7/3/23, indicated an order for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) - two puffs every four hours as needed for shortness of breath. R43's electronic medical record (EMR) lacked evidence of a self-administration of medication assessment and order for R43 to self-administer the albuterol inhaler. During observation and interview on 2/5/24 at 2:59 p.m., an albuterol inhaler, dated 9/22/23, was sitting on R43's bedside table. R43 stated a staff member had brought it in for her to take awhile ago and never took it back out. During…

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 develop and implement a system to help facilitate resident' choice and preference with regards to provided therapy services scheduling for 2 of 2 residents (R34, R58) reviewed who expressed concerns with how such services were provided. Findings include: R34's significant change in status Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition and demonstrated no delusional thinking. On 2/5/24 at 3:32 p.m., R34 was interviewed and stated she admitted to the care center from the hospital following a stroke several months prior. R34 voiced frustration and stated she felt she did not get a very good chance at therapy before she had been discharged from the service and attributed that to, in part, the lack of a set schedule or routine when therapy would be provided adding therapists would often just come in whenever. R34 stated she liked having a routine with her cares and having a therapy schedule would have helped her participate more…

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 ambulation services to maintain and prevent decline of function for 2 of 2 residents (R58 and R69) reviewed who required assistance with ambulation. Additonally, the facility failed to provided an exercise range of motion (ROM) program for 1 of 1 resident (R43) reviewed for ROM. Findings include: R69's quarterly Minimum Data Set (MDS) dated [DATE], indicated R69 had intact cognition and diagnoses of dementia, diabetes, and stroke. In addition, R69 had impairment to one side of both his upper and lower extremities and utilized a walker or wheelchair for mobility. R69's hospital Discharge summary dated [DATE], indicated R69 was involved in car accident on 7/10/23 with two left rib fractures, a thoracic (neck) vertebral fracture, and chronic compression fractures to lower thoracic vertebra (lower back bone). In addition, R69 experienced a fall at the hospital on [DATE] which resulted in a left femoral neck (hip) fracture. R69's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess a resident for safe smoking practices for 1 of 1 resident (R44) reviewed for smoking. Findings include: R44's quarterly Minimum Data Set, dated [DATE], indicated R44 was admitted to the facility on [DATE], had moderate cognitive impairment and was independent with activities of daily living. R44's care plan, dated 10/2/22, indicated R44 currently smoked in the facility, would follow the smoking policy, and have a smoking evaluation per facility policy and as needed. R44's smoking assessment, dated 7/18/23, indicated R44 was currently identified as a smoker but did not have any smoking materials so was not assessed for safe smoking practices. During an interview on 2/5/24 at 2:41 p.m., R44 stated she smoked daily, either outside the front or back entrance, and would often get cigarettes from her roommate. During an interview on 2/7/24 at 9:47 a.m., nursing assistant (NA)-D stated she first noticed R44 smoking when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess to determine what, if any, interventions were needed or available to help reduce the risk of recurrent urinary tract infections (UTI) for 1 of 2 residents (R34) reviewed who had multiple, repeated infections. Findings include: A Mayo Clinic 5 Tips to Prevent a Urinary Tract Infection article, dated 6/2022, identified the most common symptoms of a UTI were painful urination, tenderness above the bladder area, and frequent or urgent urination. The article outlined, Women are at greater risk for a UTI . UTIs also are more common in postmenopausal women because low estrogen levels change vaginal and urethral tissue to increase the risk of infection . It's always better to prevent an infection rather than simply treat it. The article included tips which were identified as having, . with little or no potential negative side effects. These included drinking plenty of fluids (i.e., at least 50 ounces daily), taking…

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 scheduled medication administration times reflected the actual, current physician orders to reduce the risk of administration error or complication (i.e. GI upset) for 1 of 5 residents (R34) reviewed for unnecessary medication use. Findings include: A Mayo Clinic Metformin (Oral Route) Proper Use article, updated 2/1/24, identified the medication was used to treat high blood sugar levels caused by diabetes mellitus. The article listed a section labeled, Proper Use, which directed to take the medication with meals to reduce the risk of stomach or bowel side effects which were most common during the first few weeks of treatment. R34's significant change in status Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition along with several medical conditions including gastroesophageal reflux disease (GERD; a digestive disease in which stomach acid or bile irritates the food pipe lining) and diabetes mellitus. R34's most recent…

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 acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or recorded prior to the administration of as-needed (i.e., PRN) psychotropic medication for 1 of 5 residents (R34) reviewed for unnecessary medication use. Findings include: R34's significant change Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS outlined R34 received antidepressant medication and anticoagulant medication (to thin the blood) but did not receive anti-anxiety medication during the review period. R34's most recent Order Summary Report, signed 1/21/24, identified R34's current physician-ordered medications and treatments. This included orders for gabapentin (an anti-convulsant medication) daily, paroxetine (an antidepressant medication) daily at bedtime, along with an order which read,…

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 pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided to reduce the risk of severe disease for 3 of 5 residents (R43, R44, R47) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults chart dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained for adults 65 years and older as outlined: -The chart indicated when a resident had received no prior pneumococcal vaccines, they should receive the pneumococcal 20-valent Conjugate Vaccine (PCV20) or the pneumococcal 15-valent Conjugate Vaccine (PCV15). -The chart indicated that when a resident with an immunocompromising condition had received the Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age, the pneumococcal polysaccharide vaccine 23 (PPSV23) at less than 65 years, and it had been eight weeks or more since the previous PCV13…

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 sufficient nursing staff to meet assessed needs and reduce the risk of adverse event (i.e., skin breakdown, range of motion decline, poor hygiene) for 1 of 2 residents (R13) reviewed for pressure ulcer care; 3 of 5 residents (R40, R43, R44) reviewed for activities of daily living (ADLs); 3 of 3 residents (R32, R40, R44) reviewed for range of motion (ROM); 3 of 4 residents (R43, R28, R44), and 8 of 8 staff members (NA-R, NA-S, NA-T, RN-O, NA-C, NA-Q, RN-F, RN-B) who expressed concerns about the lack of sufficient nursing staff at the nursing home. Findings include: ASSESSED NEEDS NOT MET: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 had severe cognitive impairment, required extensive assistance with bed mobility, and was dependent on two staff members for all transfers. Further, the MDS indicated R13 was at risk for pressure injury development and had one unhealed stage IV pressure ulcer (defined as full…

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 implement appropriate infection control protocols for 1 of 1 resident (R26) following diagnosis and confirmation of Influenza A. This had the potential to affect all 71 residents of the facility. Findings include: The current Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for Influenza, identified a resident who tests positive for Influenza should be immediately placed on standard and droplet precautions and if possible a private room. Standard precautions include performing hand hygiene before and after touching resident or environment, wearing gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated, and wearing a gown if soiling of clothes with a resident's respiratory secretions is anticipated. Droplet precautions include wearing facemask upon entering residents' room and if resident movement or transport is necessary, have the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to arrange for safe transfers out of bed for 1 of 1 resident (R52) reviewed for accommodation of needs. Findings include: R52's Face Sheet dated 12/1/22, indicated she was admitted on [DATE]. R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact. The MDS indicated transfers did not occur for R52 in the look back period of seven days. R52's admission Data Collection assessment dated [DATE], indicated R52 weighed 374 pounds, and was weighed by a Hoyer lift (a mobility tool used to help with people with mobility challenges to get out of bed, or move from surface to surface safely) scale. The assessment further indicated R52 transferred with the assistance of two or more people and used a wheelchair for mobility. R52's noted bathing preference was a tub bath. R52's baseline care plan dated 5/11/22, indicated assist with mobility in and out of bed and assist with transfers with a Hoyer lift. R52's care plan dated 5/13/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R18) reviewed for dialysis; and 1 of 1 residents (R13) reviewed for hospice care coordination. Findings include: R18's significant change Minimum Data Set (MDS), dated [DATE], indicated R18 had intact cognition and required limited assistance of one staff for dressing, supervision with one-person physical assistance for personal hygiene and was independent for all other activities of daily living (ADLs). Section O Special Treatments and Programs indicated R18 was on dialysis while a resident in the facility. R18's diagnoses included chronic heart failure (CHF), end stage chronic kidney disease (CKD), diabetes, and chronic embolism and thrombosis (blood clots). R18's Care Area Assessment (CAA) dated 11/11/22, indicated R18 triggered for ADL function. R18's care plan dated 10/3/22, indicated R18 was on a therapeutic diet related…

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 ensure activities of daily living (ADLs) including weekly baths were provided for 3 of 3 residents (R40, R43, R44) who needed assistance with bathing. In addition, the facility failed to implement a communication system to ensure resident needs were met for 1 of 1 residents (R44) who's primary language was not English. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition and required limited assistance of one staff for bed mobility, transfers, and personal hygiene, and extensive assistance of one staff for dressing and toileting. The MDS indicated R40 required physical help in part of bathing and used a walker and/or wheelchair for mobility. The MDS also indicated R40 did not have a history of refusing cares during the assessment period. R40's diagnoses included major depressive disorder high blood pressure, diabetes, chronic heart failure (CHF), candidiasis (fungal growth), obesity, and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) and meal set-up was offered or provided to 1 of 4 residents (R5) reviewed for activities of daily living (ADLs) and who was dependent on staff for care. In addition, the facility failed to ensure personal hygiene and incontinence care was provided to 1 of 1 resident (R13) who had bowel incontinence and required staff assistance for care. Findings include: R5's Face Sheet dated 12/1/22, indicated a diagnosis of dementia. R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was moderately cognitively impaired, and required supervision, oversight, or cueing for ADLs and set-up for meals. R5's care plan printed dated 3/30/21, indicated R5 had a self-care deficit related to weakness and memory issues and indicated staff assist with personal hygiene. The care plan did not mention R5 required meal set-up. R5's nursing assistant (NA) care sheets lacked instruction for shaving or meal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively reassess and develop or implement meaningful and engaging activities for 1 of 3 residents (R13) reviewed who had an expected decline in condition and could no longer participate in activities as once prior. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had severe cognitive impairment and was almost totally dependent on staff for her activities of daily living (ADLs). R13's most recent MHM (Monarch Healthcare Management) Activity Participation Review, dated 9/19/22, identified R13 passively participated in group gatherings and independent leisure activities. R13 was recorded as tiring easily, being non-verbal, and needing assistance to attend activities. The assessment outlined R13 had attended religious gatherings, being read to, rest and relaxation, listening to television/music within the past 30 days. Further, a section labeled, Activity Plan Review, identified R13's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and provide interventions for developed skin irritations for 1 of 1 resident (R37) reviewed for non-pressure skin concerns. In addition, the facility failed to approrpiately monitor hydration-related interventions for efficacy to reduce the risk of urinary tract infection (UTI) for 1 of 1 resident (R19); and failed to ensure adequate and appropriate coordination of care with an outside hospice agency for 1 of 1 resident (R13) reviewed for hospice care. Findings include: SKIN IRRITATION: R37's annual Minimum Data Set (MDS) dated [DATE], indicated no skin issues, but indicated ointment was applied to skin other than to the feet. R37's face sheet dated 12/1/22, listed R37's current medical diagnoses, which did not include any mention of skin issues. R37's provider active orders dated 7/25/22, indicated Nystatin powder [anti-fungal medication] under folds three times daily for yeast dermatitis [skin inflammation].…

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 services to maintain vision for 1 of 1 resident (R52) reviewed for visual impairment. Findings include: R52's Face Sheet dated 12/1/22, indicated she was admitted to the facility on [DATE]. R52's Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact, and further, indicated R52 wore corrective lenses. R52's admission Data Collection assessment dated [DATE], indicated R52 wore corrective lenses and her last eye appointment was, About a year ago. R52's Interdisciplinary Team (IDT) progress note dated 10/11/22, indicated R52 voiced concerns in need to follow up with her eye doctor. R52's progress note dated 5/18/22, indicated R52 complained of double vision and would like to be seen for some eye care. The note further indicated staff would arrange an eye care visit with either the in-house eye care provider or would talk to R52 about other options. R52's clinical record lacked evidence of a signed consent form for eye care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide timely repositioning and complete weekly skin monitoring, in accordance with the care plan and assessed needs, to reduce the risk or pressure injury development and/or worsening for 1 of 2 residents (R13) reviewed for pressure injuries. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 had severe cognitive impairment, required extensive assistance with bed mobility, and was dependent on two staff members for all transfers. Further, the MDS indicated R13 was at risk for pressure injury development and had one unhealed stage IV pressure ulcer (defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling). R13's most recent MHM (Monarch Healthcare Management) Braden Scale, dated 9/15/22, identified R13 was at high risk for pressure injuries and skin breakdown and listed a section…

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 ensure 3 of 3 residents (R32, R40, R44) received restorative therapy and range of motion (ROM) exercises to prevent potential decline in ROM and/or mobility. Finding include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had a Brief Interview for Mental Status (BIMS) score of 99 indicating R32 was unable to complete the test. R32's diagnoses included a stroke affecting R32's right dominant side, congestive heart failure (CHF), atrial fibrillation (an irregular heartbeat increasing the formation of clots in the heart), diabetes, dysphagia (difficulty swallowing), chronic kidney disease (CKD), high blood pressure, skin cancer, and lymphoma (lymph node cancer). R32's Care Area Assessment (CAA) dated 6/26/22, indicated R32 triggered for communication, activities of daily living (ADLs), cognitive loss/dementia, and pressure ulcers. R32's care plan dated 6/2/22, indicated R32 had an alteration in mobility related to a stroke.…

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 identify, comprehensively assess, and implement interventions for 1 of 1 residents (R32) who had an unplanned weight loss of greater than 10% in three months. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified, severe cognitive impairment with diagnoses including a stroke, heart failure, diabetes and dysphagia (difficulty swallowing). R32 required supervision and set up for eating. The MDS also identified R32 had a loss of liquids/solids from mouth while eating and had an unplanned weight loss of 5% or more in the previous 6 months. R32's Care Area Assessment (CAA) dated 6/26/22, indicated R32 triggered for nutrition and referred to R32's care plan for interventions. R32 also triggered for communication, activities of daily living (ADLs), cognitive loss/dementia, and pressure ulcers. R32's care plan dated 9/22/22, indicated R32 was on a mechanically altered diet with honey thickened liquids. The care plan also indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to monitor for complications related to dialysis and a dialysis access port for bleeding and/or infection for 1 of 1 residents (R43) reviewed for dialysis care. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition, was on dialysis and had diagnoses including, heart failure, kidney failure and diabetes. R18's care plan dated 10/3/22, included they were at risk for eight changes due to dialysis treatment and was on a therapeutic diet due to heart failure, kidney disease and diabetes and staff were to communicate with the dialysis interdisciplinary team. However, the care plan did not identify when they went to dialysis or any monitoring related to dialysis treatment or how to assess, monitor or care for R18's dialysis access port. During an interview on 11/28/22, at 6:52 p.m. R18 stated she had an access port on her upper chest for dialysis and that staff did not assess it or provide any care for 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 document review the facility failed to arrange assessment and treatment for dental care for 2 of 4 residents (R52 and R3) reviewed for dental care. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact. R52's significant change MDS dated [DATE], indicated R52 had obvious or likely cavities or broken teeth. R52's admission Data Collection assessment dated [DATE], lacked assessment of R52's ability to chew. The assessment indicated R52 reported she had fillings coming out as well as broken teeth. R52's care plan dated 6/6/22, directed staff to provide dental visits as needed. R52's progress note dated 5/18/22, indicated R52 complained of mouth pain and showed interest in dental services. R52' facility Oral/Dental Evaluation dated 6/28/22, indicated fillings had fallen out and a tooth had crumbled over the previous few months, and R52 wanted to see a dentist. R52's Appletree Dental progress note dated 9/13/22, indicated only a brief exam…

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.