The Estates At Fridley LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure coordination of care and communication between the facility and the dialysis center for 1 of 1 residents (R21) who received hemodialysis. Findings include:R21's admission minimum data set (MDS) dated [DATE], indicated R21 had diagnoses of anemia, hypertension, renal insufficiency, renal failure, or end stage renal disease (ESRD) and was receiving hemodialysis. Additionally, the MDS indicated R21's brief interview of mental status (BIMS) score was 15 indicating R21 was cognitively intact.During interview on 8/4/25, at 5:40 p.m., R21 stated he attended dialysis three days per week on Tuesday, Thursday and Saturday.R21's clinical physician orders report printed 8/7/25, indicated the following orders: hemodialysis scheduled every Tuesday, Thursday and Saturday at Davita Dialysis Center of [NAME], monitor dialysis site for bleeding, monitor fistula for bruit and thrill, complete post dialysis vital signs, complete dialysis communication form 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 record review, the facility failed to properly dispose of controlled medication for 2 of 2 residents (R57, R58) reviewed for disposal of medications after discharge.R57's death in facility minimum data set (MDS) dated [DATE], included R57 was discharged /deceased on [DATE].R57's Order Summary Report printed [DATE], included an order for lorazepam oral concentrate 2 mg/ml (a medication give for anxiety) give 0.25 milliliters (mL) by mouth every 2 hours as needed for restlessness and anxiety AND give 0.25 mL by mouth every 4 hours for restlessness and anxiety.During tour of medication room on [DATE] at 1:50 p.m., assistant director of nursing (ADON) opened lock box used to store controlled substances requiring refrigeration. Lock box contained a box containing a bottle with a label that identified it as lorazepam 2mg/ml for R57. ADON was unable to locate tracking page for R57's lorazepam in narcotic book currently being used in the facility. ADON was able to locate the tracking…

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 properly store controlled substances in 1 of 1 medication rooms reviewed for medication storage.During tour of medication room on 8/6/25 at 1:50 p.m., assistant director of nursing (ADON) showed the unlocked medication refrigerator with small unaffixed lockbox. ADON removed the lockbox from the refrigerator and unlocked it to show 6 controlled medications in the lock box. During interview on 8/6/25 at 1:50 p.m., ADON confirmed the lockbox was not permanently affixed to the refrigerator. ADON stated the facility had explored options to attach the lock box but had not yet found a solution. ADON described the box as similar to the size of an iPad and about 4 inches thick. ADON confirmed the whole box could be removed from the medication room. During interview on 8/7/25 at 8:13 a.m., director of nursing (DON) stated controlled refrigerated medications were stored in the refrigerator in the locked medication room in a lock box. The DON confirmed the lock box was not permanently affixed to the refrigerator because…

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 was performed when providing wound care for 1 of 3 residents (R2) reviewed for pressure ulcer care. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment and moisture associated skin wounds. R2's care plan dated 4/6/25 indicated enhanced barrier precautions (EBP, measures intended to prevent the spread of multi-drug-resistant organisms) related to a catheter and wounds. The care plan further directed staff should don/doff personal protective equipment (PPE) per EBP when providing high contact care. The care plan was revised on 5/29/25, and indicated R2 had a pressure ulcer on the left lateral foot, and staff would monitor for signs and symptoms of infection. R2's wound care orders dated 5/27/25, indicated apply Santyl (prescription ointment to treat wounds) to the left lateral foot wound topically every evening shift every Tuesday, Thursday, 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.

Based on interview and document review, the facility failed to ensure annual performance reviews were completed for 1 of 1 nursing assistants (NA-A) whose personnel files were reviewed. This deficient practice had potential to affect all residents who currently resided in the nursing home and who could receive care from this staff. Findings include: NA-A was hired on 10/27/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. On 4/21/25 at 12:14 p.m., during an interview NA-A stated he was hired in October 2023, and had not had a performance evaluation. On 4/21/25 at 4:22 p.m., during an interview the director of nursing stated performance reviews were expected to be completed every 12 months, and acknowledged NA-A's performance review was due in October 2024, and had not been completed. A policy on performance reviews was requested; the facility did not have a policy about performance reviews.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an allegation of potential abuse for 1 of 1 resident (R1) who complained of rough care by staff, was reported immediately but no later than 2 hours to the State Agency (SA). Findings include: On 4/21/25, a review of a facility Grievance Form dated 4/6/25, indicated [NAME] police contacted the facility and spoke to the Social Services Director (SSD) and informed the SSD a Minnesota Abuse Reporting Center (MAARC) report was filed indicating a nursing assistant (NA) was rough when getting R1 into his wheelchair on 4/6/25 around 4:30 p.m., and R1's leg and abdomen were subsequently hurting. On 4/21/25, the SSD was not available for interview. On 4/21/25 at 11:51 a.m., during an interview registered nurse (RN)-A stated when she learned of any type of abuse, she was expected to report it to the director of nursing (DON) right away, and the facility had 24 hours to report it to the SA. On 4/21/25 at 12:35 p.m., during an interview NA-A stated if he…

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 a registered nurse (RN) was scheduled for a minimum of 8 consecutive hours a day. This had the potential to affect all 35 residents who resided at the facility. Findings include: Review of the facility daily staffing hours and staff schedules from 2/1/24-4/30/24, indicated there was no RN scheduled on the following dates: 2/10/24, 2/17/24, 2/18/24, 2/25/24, 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, 3/32/24, 4/6/24, 4/7/24, 4/13/24, 4/14/24, 4/20/24, 4/21/24, 4/27/24, and 4/28/24. During interview on 5/01/24 at 2:38 p.m., the staffing coordinator verified there was not an RN working 8 consecutive hours on the dates above and stated they do not have any RN's on staff except the assistant director of nursing (ADON), the director of nursing (DON), and the occasional agency/pool nurse. The staffing coordinator further stated the ADON and DON are not included on the schedule during the week so they can be pulled in if needed. They are not scheduled to work on the weekends but take…

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 ordered podiatry care for 1 of 1 resident (R23) reviewed for foot care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and extensive assist required with personal hygiene and bathing. Diagnoses included of heart failure (affects blood circulation), respiratory failure, hypertension, morbid obesity, and candidiasis (fungal infection) of nail. Anticoagulant medication was taken daily. R23's care plan dated 3/29/24, identified self-care deficit related to history of repeated falls, bilateral osteoarthritis, chronic pain, weakness, morbid obesity, difficulty walking, muscle weakness, other fatigue, other abnormalities of gait. Assist of one staff was required with personal grooming and hygiene. R23's nurse practitioner order dated 7/21/23, identified consult podiatry for diagnosis of overgrown toenails. R23's medical record dated 7/21/23 through 5/2/24, lacked documentation 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 prescribed medications were available for 1 of 1 resident (R23) who was awaiting a new medication. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and extensive assist required with personal hygiene and bathing. Diagnoses included heart failure (affects blood circulation), respiratory failure, hypertension, and morbid obesity. There were no ulcers, wounds, skin problems or skin treatments identified in the MDS. R23's activities of daily living (ADL) care area assessment (CAA) dated 6/8/23, identified the CAA triggered since resident needed extensive assist with most ADLs related to her respiratory condition and morbid obesity. R23's care plan dated 8/11/23, identified an alteration in skin integrity due to multiple areas of self-inflicted skin tears. The goal was to have skin breakdown resolved by next review. Skin was to be monitored daily during cares, weekly skin inspection by 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.

Based on observation, interview, and document review, the facility failed to ensure the pharmacist recommendations were implemented timely for 1 of 5 residents (R9) reviewed for unnecessary medications. Findings Include: R9's annual Minimum Data Set (MDS) indicated R9's diagnosis included coronary artery disease, hypertension, hyperlipidemia and was on antiplatelet medication. R9's care plan initiated 2/16/23, lacked documentation for coronary artery disease and hyperlipidemia goals or interventions. R9's physician orders dated 2/16/23, indicated rosuvastatin calcium oral tablet, give 10 mg by mouth at bedtime for hyperlipidemia. R9's pharmacy medication regimen review (MRR) were as follows: -3/6/24, pharmacy MRR indicated, note: reissued recommendation from 2/6/24, this resident continues on rosuvastatin 10 milligram every bedtime and Fenofibrate 54 mg every day treating hyperlipidemia, does not have type II diabetes. I was unable to locate a lipid panel. If not recently drawn, please clarify if a lipid panel should be drawn to evaluate the ongoing use of Fenofibrate. A provider…

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 antipsychotic medication was not started without adequate medical justification; and that a discussion of risks, benefits and potential side effects was understood by the resident, representative, or family for 1 of 1 resident (R30) reviewed who had a newly prescribed antipsychotic. In addition, the facility failed to include individualized approaches for care, including behavior tracking and non-pharmacological interventions for 2 of 4 residents (R30 and R89), and failed to ensure as needed (PRN) antipsychotic medication was not used longer than 14 days without the resident being directly evaluated by the prescriber for 1 of 2 residents (R89) reviewed for unnecessary medications. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. No psychosis, rejection of care, or behaviors occurred in the lookback period. Diagnoses included head injury, communication deficit, muscle weakness. 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 1 of 5 residents (R9) was offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC Pneumococcal Vaccine Timing for Adults dated 3/15/23, 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…

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 a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 44 residents who resided at the facility. Findings include: Review of the facility daily staffing hours and staff schedules from 4/1/23 through 4/30/23, revealed there was no RN scheduled on-site during the following weekends: - 4/1/23 through 4/2/23 - 4/8/23 through 4/9/23 - 4/15/23 through 4/16/23 - 4/22/23 through 4/23/23 - and 4/29/23 through 4/30/23. On 5/10/23 at 1:01 p.m., the administrator reviewed the daily staff posting and stated a 0 under the 'staff hours column' means there was no RN scheduled. A 1 in the 'number of staff column' indicates the DON would have covered. During interview on 5/11/23 at 9:13 a.m., the administrator stated there is always an RN in the facility Monday through Friday. The administrator stated at least one weekend a month, if not more, there is not an RN working in the building and the assistant director of nursing (ADON) or the director of nursing (DON)…

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 Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys in regards infection control and self-administration of medications (SAM) which were also identified during this survey. This had the potential to effect all 44 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 5/1/23, identified the facility was cited F880 for infection control on the surveys which exited 7/11/19 and 9/16/21. The facility was also cited F554 for SAM on the survey which exited 9/16/21. See F880: Based on observation, interview, and document review the facility failed to ensure staff wore appropriate personal protective equipment (PPE) appropriately for 1 of 2 residents (R31) who was on transmission based precautions (TBP). See F554: Based on observation, interview, and document review, the facility failed to assess the resident and determine safety for SAM for 2 of 2 residents (R34…

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 remove facial hair and maintain dignity for 1 of 3 residents (R4) reviewed for dignity. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment, and required one-person physical assistance for personal hygiene to include shaving. R4's diagnoses included schizoaffective disorder, obsessive compulsive disorder, intellectual disability, unspecified psychosis, and anxiety disorder. R4's care conference note dated 4/5/23, indicated, interdisciplinary team (IDT) met with family member (FM)-A for a quarterly conference. The note indicated, The family has requested facila [sic] shaving to occur during her showers - need care notes updated. R4's care plan dated 3/21/23, indicated R4 was at risk for impaired ability to complete activities of daily living (ADLs) due to cognitive impairments and mental health and required supervision with set up for grooming and personal hygiene. R4's nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to assess and determine safety for self-administration of medications (SAM) for 2 of 2 residents (R34 and R243) whom were observed to have medications in their rooms. Findings include: R34's admission Minimum Data Set (MDS) dated [DATE], identified R34 was cognitively intact and required assistance of 1-2 staff with activities of daily living (ADL's) including bed mobility, dressing and personal hygiene. R34's diagnoses included altered mental status, psychotic disorder with delusions, bipolar disorder and muscle weakness. R34's Order Summary Report dated 5/11/23, included Triamcinolone Acetonide External Cream 0.5% (a medication used to treat symptoms including itching, dryness, and inflammation caused by various skin conditions) topically for urticaria (hives). The physician orders lacked SAM orders. R34's care plan dated 4/18/23, failed to identify skin conditions and interventions that included SAM. During observation on 5/09/23 at…

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 timely follow up on a resident requested medication change for 1 of 2 residents (R17) reviewed for choices. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified she had intact cognition and had not rejected cares. R17 had a diagnosis of end stage renal disease. R17 required supervision for dressing and limited assist for hygiene. R17's medication orders included: -start date of 12/7/2022, cetirizine hcl (hydrocloride) (an antihistamine) oral tablet five mg (milligrams) by mouth every 24 hours as needed related to allergic rhinitis. R17's Communication Form dated 4/14/23, identified a request of R17 for Zyrtec (brand name for cetirizine) to be scheduled, as the medication was PRN (as needed) at this time. The provider's written response on 4/17/23, was pls [please] re-ask the question. During an observation and interview on 5/09/23 at 9:09 a.m., R17 had dry, red eyes and rubbed her nose. R17 stated I have…

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 revise care plan interventions with recommended behavioral approaches for 1 of 1 residents (R29) reviewed for mood and behavior. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified he had intact cognition and had rejected cares one to three days in the look back period. R29 was independent with ambulation and toileting. R29 had a diagnosis of encephalopathy (brain disease, damage, or malfunction that can cause an altered mental state.) R29's Associated Clinic of Psychology (ACP) visit note dated 4/5/23, identified it was important for staff to replace R29's linens when they removed items. Further, it was important to replace the items as soon as possible to help decrease R29's concerns of items were stolen. R29's mood and behavior care plan dated 4/10/23, lacked the recommended intervention to replace any removed linens. During an observation on 5/9/23 at 11:07 a.m., R29 was yelling loudly in the hallway for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure pharmacy recommendations were addressed for 1 of 1 resident (R4) reviewed for antipsychotic medication side effects. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment, and had received antipsychotics 7 of the 7 days during the lookback period. R4's diagnoses included schizoaffective disorder, obsessive compulsive disorder, intellectual disability, unspecified psychosis, and anxiety disorder. R4's provider orders indicated Risperdal tablet 1mg (milligram). Give 1 mg by mouth every morning and at bedtime for schizoaffective disorder. R4's care plan dated 3/21/23, indicated R4 had potential for psychotropic drug ADR's (adverse drug reactions) related to daily use of psychotropic medication. R4's consultant pharmacist medication regimen review (MRR) recommendation dated 11/3/22, indicated, This resident takes Risperidone, a medication that can cause metabolic abnormalities including…

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 timely arrange for an ordered urology examination 1 of 1 resident (R29) reviewed who required diagnostics services. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. R29 was independent with ambulation and toileting. R29's had a diagnosis of encephalopathy (brain disease, damage, or malfunction that can cause an altered mental state.) R29's orders dated 12/2/22, identified please schedule urology appointment to evaluate and treat for urinary incontinence- may need urodynamic studies. R29's physician visit notes identified the following: -12/16/22, R29 reported frequent urination and urinary incontinence. R29's room smelled of urine, but R29 did not smell of urine. R29 was asked about the urologist and R29 reported not seeing one yet. The note added a diagnosis of functional urinary incontinence and would discuss with staff a urology follow up. -1/23/23, R29 continued to report frequent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) appropriately for 1 of 2 residents (R31) who was on transmission based precautions (TBP). Findings include: R31's significant change Minimum Data Set (MDS) dated [DATE], identified R31 was cognitively intact and was frequently incontinent of bowel and bladder. The assessment identified R31 required extensive assist from one or more staff for toileting, bed mobility, transfers, and personal hygiene. R31's diagnoses included diabetes mellitus, heart disease, peripheral vascular disease, and methicillin resistant staphylococcus aureus (MRSA) infection. The assessment lacked diagnosis of urinary tract infection with vancomycin-resistant enterocolitis (VRE - an infection in the urine that is resistant to vancomycin antibiotics, is usually spread from person to person through contact with infected people or people who carry the bacteria without it causing infection within…

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 2 of 5 residents (R2 and R35) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC's Pneumococcal Vaccine Timing for Adults dated 3/15/23, identified adults 65 years or older who had not previously received any pneumococcal vaccine, one dose of PCV15 or PCV20 (pneumococcal conjugate vaccines) should be administered. If PCV15 was used, this should be followed by a dose of PPSV23 (pneumococcal polysaccharide vaccine) at least 1 year later. R2's face sheet undated, identified he was [AGE] years old and admitted on [DATE]. R2 had no allergies to vaccines or contraindications to vaccines listed. R2's immunization record undated, lacked documentation of the pneumococcal vaccine. R2's Resident Vaccine Administration Consent form undated, identified he declined the influenza and COVID-19 vaccines but lacked documentation of the pneumococcal vaccine. R35'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 interview and document review, the facility failed to provide the COVID-19 vaccination timely to 1 of 1 resident (R37) whom requested to be vaccinated. Findings include: R37's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition. R37 required limited assistance with dressing and hygiene. R37's diagnoses included stroke with paralysis on one side of the body and pulmonary disease. R37's face sheet undated, identified she was [AGE] years old and was admitted on [DATE]. R37 had no allergies to vaccines or contraindications to vaccines listed. R37's immunization sheet undated, identified she had one dose of a COVID-19 vaccine on 8/11/21. R37's Resident Vaccine Administration Consent Form dated 2/7/23, identified the COVID-19 vaccine would be completed by the facility. During an interview on 5/9/23 at 4:00 pm., R37 stated staff offered the COVID-19 vaccine when she was admitted but it had not been administered yet and she still wanted the vaccine. During an interview on 5/11/23…

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.