Guardian Angels Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a resident did not self-administer medications (SAM) as assessed and according to the care plan for 2 of 2 residents (R40, R219) reviewed for SAM. Findings include: R40: R40's admission Minimum Data Set (MDS) dated [DATE], identified R40 had diagnoses which included chronic obstructive pulmonary disease (COPD [a group of lung disease that block airflow and make it difficult to breathe]), mild cognitive impairment, and supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers). In addition, R40 required partial to moderate assistance with activities of daily living. R40 had no rejections of care. R40's Order Summary Report current as of 6/12/25, identified R40 had orders for ipratropium-albuterol (used to treat COPD by opening the airways and reducing inflammation) inhalation solution 0.5-2.5 (3) milligrams per 3 milliliters one vial inhale orally three times a day dated 6/10/25.…

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 timely reveiw and revision of the care plan occured for 2of 2 residents (R41, R11) reviewed for care planning. Findings include: R41: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was moderately cognitively impaired with the diagnoses of stroke, dysphagia, generalized muscle weakness, and epilepsy. MDS Section GG indicated R41 was dependent for activities of daily living and transfers. R41's Care plan last revised 6/3/25, identified R41 as a risk for falls on 3/19/25. The care plan lacked evidence to show R41's fall prevention interventions had been revised before or after R41's fall on 6/7/25. A nursing note entry made on 6/7/25, identified R41 had been placed in their recliner and then was later found on the floor. Post assessment revealed R41 had not sustained a significant injury. A nursing note entry made on 6/10/25, indicated an interdisciplinary disciplinary review had been completed for R41's fall on 6/7/25, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure competent, trained staff operated tube feeding pumps and managed tubing for 1 of 1 resident (R41) reviewed for tube feeding. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was moderately cognitively impaired with the diagnoses of stroke, dysphagia, generalized muscle weakness, and epilepsy. MDS Section GG indicated R41 was dependent for activities of daily living and transfers. MDS Section K. Percent Intake by Artificial Route indicated R41 received 51% or more of nutrition through parenteral or tube feeding. R41's care plan last revised 6/3/25, indicated R41 required tube feeding related to dysphasia and directed staff to use infection control precautions and related techniques following the manufacturer's recommendations when stopping, starting, flushing, and giving medications through the feeding tube. R41's Order Summary Report Active orders as of 6/12/25 included the following orders: -NPO…

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 residents were educated on and offered pneumococcal and influenza vaccinations upon admission for 1 of 5 residents (R38) admitted before 3/31/25 and failed to offer and educate on pneumococcal vaccinations for 1 of 5 residents (R59) who were reviewed for vaccinations. Findings include: R38's admission Record identified an admission date of 3/11/25, and diagnoses of and kidney failure, heart disease and urinary tract infection. R38's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. R59's admission Record identified an admission date of 4/25/25, and diagnoses of status post-kidney transplant, chronic kidney disease, and immunodeficiency. R59's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. During an interview on 6/11/25 at 3:06 p.m., registered nurse (RN)-F stated the facility did a vaccination reconciliation within 48 hours, it was part of the admit paperwork along 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 interview and document review, the facility failed to ensure residents were educated on and offered COVID-19 vaccinations upon admission for 2 of 5 residents (R38, R59) reviewed for vaccinations. Findings include: R38's admission Record identified an admission date of 3/11/25, and diagnoses of and kidney failure, heart disease and urinary tract infection. R38's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. R59's admission Record identified an admission date of 4/25/25, and diagnoses of status post-kidney transplant, chronic kidney disease, and immunodeficiency. R59's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. During an interview on 6/11/25 at 3:06 p.m., registered nurse (RN)-F stated the facility did a vaccination reconciliation within 48 hours, it was part of the admit paperwork along with checking the Minnesota Immunization Information Connection (MIIC) for history. RN-F reviewed R38 and R59's record and confirmed there was no…

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 resident call lights were within reach from the bathroom floor in a resident bathroom for 1 of 2 residents (R17) and failed to ensure bathroom call light was in good repair for 1 of 2 residents (R27) reviewed for call light accessibility. Findings include: On 6/9/25 at 3:22 p.m., the bathroom call light for R17 was checked to see if it was in working order. The bathroom call light did not have a cord. On 6/10/25 at 1:30 p.m., the bathroom call light for R27 was checked to see if it was in working order and the cord was found to be frayed in the middle of the red cord, able to see white thread. On 6/11/25 at 1:55 p.m., maintenance (M)-A verified the call light in R27's bathroom was frayed and stated in needed to be replaced because it could break. M-A verified R17 had no call light cord in the bathroom. M-A verified it was a safety concern if a resident fell in the bathroom they would not be able to reach the button on the wall and call for help. During an interview on 6/11/25 at 3:47 p.m., the administrator stated…

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 unauthorized staff, visitors, and residents did not have access to medication storage area. This practice had the potential to affect all residents on the 400 hallway. Findings include During observation on 7/16/24 at 7:18 a.m., the 400 hallway medication storage area doorway was completely open with no staff around the medication storage area or the nurses desk next to the medication storage area. During observation on 7/16/24 at 8:33 a.m. the 400 hallway medication storage area doorway was open and nursing staff were not around the medication storage area. The nurse manager was in her office, next to the medication storage area but had her back facing her door and the medication storage area. During an interview on 7/16/24 at 8:37 a.m., registered nurse (RN)-C confirmed the medication storage room was open and no staff were around except her, with her back facing the medication storage room. RN-C stated it was the responsibility of the nurse working the cart to make sure the medication storage room…

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 reviewed the facility failed to comprehensively assess and document a resident with a contracture to the right hand. This affected 1 of 3 residents (R8) reviewed for limited range of motion. Findings include: R8's admission Minimal Data Set (MDS) dated [DATE], identified R8 had minimal cognitive impairment. Diagnoses included bilateral lower extremity amputations, anemia, and renal insufficiency. The MDS also indicated R8 had no functional limitation to range of motion to the upper extremities which included the shoulder, elbow, wrist, or hand. R8's admission assessment dated [DATE], indicated R8 had no impairments to his upper extremity which included the shoulder, elbow, wrist, or hand. During an observation on 7/14/24 at 2:03 p.m., R8 was noted to have a contracture to his right hand and fingers on the right hand. During an interview on 7/14/24 at 2:05 p.m., R8 stated the contracture to his right had and fingers had been there for over 2 years. On 7/16/24 at 1:18…

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 comprehensively assess and care plan services for 2 of 3 residents (R162, R8) reviewed for care plan accuracy. Findings include: R162: R162's admission Minimum Data Set (MDS) dated [DATE], reflected a facility entry date of 7/3/24, identified impaired cognition, diagnoses of lung and colon cancer, and R162 received hospice services. R162's care plan dated 7/3/24, did not include a focus for hospice care and coordination. A document, St. Croix Hospice IDG Comprehensive Assessment and Plan of Care Report identified a hospice admission of 2/1/24. During an interview on 7/17/24 at 1:00 p.m., registered nurse (RN)-A confirmed R162's care plan did not contain hospice and R162 was on hospice services upon admission on [DATE]. During an interview on 7/17/24 at 1:00 p.m., the director of nursing (DON) stated she would expect there to be a line item for hospice in the care plan because it was important for coordination of care. A document, Person Centered Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to follow provider orders for residents requiring weight monitoring for 2 of 4 residents (R42, R33) reviewed for unnecessary medications. Findings include: R42: R42's admission Minimum Data Set (MDS) dated [DATE], identified impaired cognition and diagnoses of Alzheimer's dementia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD), and atherosclerotic heart disease (a condition that causes a narrowing of the arteries). R42's care plan dated 4/17/24, did not address obtaining or assessing resident's weight. R42's provider orders contained an order for weekly weights starting 5/6/24. Review of R42's electronic medical record (EMR), identified no weight entries from 6/28/24 to 7/14/24. During an interview on 7/16/24 at 1:43 p.m., nursing assistant (NA)-A stated the nursing aids were responsible for weighing the residents and recording the number on the bath sheet and the nurse will enter that in their chart. During an interview on 7/17/24…

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 a rationale was documented for the order of an as needed (PRN) psychotropic (effecting the chemical makeup of the brain) medication beyond 14 days for 1 of 5 residents (R32) reviewed for unnecessary medications. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and had diagnoses of Alzheimer's disease, dementia, displaced fracture of the right femur, and history of breast and colon cancers. R32's physician order dated 10/5/2022 with no end date, identified Ativan oral tablet 0.5 milligrams (mg) give by mouth PRN up to every four hours for anxiety and hallucinations. R32's medication administration record (MAR) for 7/1/24 to 7/14/24 identified R32 receiving PRN Ativan 14 times. During an interview on 7/17/24 at 12:16 p.m., assistant director of nursing (ADON) stated the interdisciplinary team (IDT) consults with pharmacy every month to go over pharmacy review recommendations. ADON…

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 enhanced barrier precautions (EBP) were followed for 2 of 3 residents (R42, R21) who had an indwelling catheter. In addition, the facility failed to ensure EBP were put in place for 1 of 1 resident (R12) with a chronic wound. The deficient practices had the potential to place these residents at an increased risk for transmission of infection. Findings include: R42: R42's admission Minimum Data Set (MDS) dated [DATE], identified impaired cognition and diagnoses of diabetes mellitus, benign prostatic hypertrophy (BPH, enlargement of the prostate), and urinary retention. The MDS further indicated R42 had an indwelling urinary catheter and needed staff assistance with dressing, grooming, bathing, transferring and toileting. R42's provider orders dated 4/24/24, identified an order for enhanced barrier precautions due to an indwelling urinary catheter. Gown and gloves must be worn when providing personal care or emptying the catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to ensure an ordered range of motion (ROM) program was provided consistently for 4 of 4 resident (R3, R5, R6, and R7) reviewed for positioning and mobility. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 had dementia with severe cognitive impairment, and required extensive assistance for bed mobility and transfers. R3's care plan revised 1/30/24 indicated R3 had a need for restorative intervention of an ambulation program of 200 feet with each walk. R3's Restorative Nursing Program form dated 6/1/22 indicated R3 would walk 200 feet daily with walker, gait belt, and stand by assist from staff. R3's Restorative Ambulation Record from 12/7/23 to 2/7/24, indicated ambulation was proved to R3 ten times, on 12/11/23, 12/12/23, 12/30/23, 1/3/24, 1/4/24, 1/5/24, 1/8/24, 1/13/24, 1/19/24, and 1/28/24. R5's significant change MDS dated [DATE] indicated R5 was cognitively intact, needed partial/moderate assistance with walking,…

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 physician and resident representative were timely notified of a change of condition for 1 of 3 residents (R1) who had a status change resulting in a delay of medical diagnoses and treatment. Findings include R1's Face Sheet identified R1 had the following diagnosis: Parkinson's disease R1's quarterly Minimum Data Set (MDS) dated [DATE] identifies R1 to have had moderate cognitive impairment. Required assist of one for bed mobility, dressing, toilet use and assist of two for transferring. R1's care plan dated 1/30/22, identified R1 required assist to safely transfer from one surface to another and staff were to monitor for changes in abilities. R1's progress note dated 9/8/23 at 11:23 a.m., included R1 weak, not eating, drooling, eyes glassed over, and left side of mouth drooping. No responding to questions. Resident appears to have possible stroke. Called MD and gave verbal orders to send to emergency room (ER). Family present signed bed…

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 anti-Parkinson's medication was administered with in accordance with manufacturer's recommendations, and physician orders to prevent or reduce the risk of adverse side effects. Additionally failed to identify, report, and analyze medication errors in accordance with facility policy and standards of practice for 3 of 3 (R1, R2, R3) residents who received anti-Parkinson's medications. Findings include R1's Face Sheet identifies R1 had diagnoses that included Parkinson's disease. R1's quarterly Minimum Data Set (MDS) dated [DATE] identified R1 had moderate cognitive impairment. R1 required assist of one for bed, mobility, dressing, toilet use, and assist of two for transferring. R1's physicians orders included -Ferrous sulfate oral tablet (iron) to be given in the afternoon every day at 4:00 p.m. (start date 5/4/23) -Sinemet (carbidopa-levodopa) 25-100 milligrams (mg) five times per day every day at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 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 revise or update care plans for 3 of 7 residents (R10, R4, R43) and failed to provide quarterly care conferences for 1 of 7 residents (R28) reviewed for care planning. Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R10 was cognitively intact. Diagnoses included, congestive heart failure and hypertension. The Care Area Assessment indicated Dehydration was a specialized area to be addressed for R10. R10's Census report undated, indicated R10 was out of the facility on 5/22/23 due to hospitalization. R10's readmission orders dated 6/4/23, included 750 milliliter (ml) fluid restriction, daily weights and to notify provider if more than 2 (two) pound(lb) weight gain in twenty-four hours or 5 lbs in one week, daily intake and output (I&O) due to the fluid restriction for accurate monitoring. R10's care plan dated 8/26/22 indicated R10 was on a 1500 ml fluid restriction. The care plan lacked updates 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 880 Based on observation, interview, and record review the facility failed to have a surveillance program in place, procedure to notify staff and visitors of precautions for contact isolation. In addition, the facility staff failed to follow standard of practice for hand hygiene and catheter cath for 2 residents (R19, R2) reviewed for infection control. This had the potential to affect 65 residents in the facility. Findings include: R19's Face Sheet, indicated R19 had diagnoses which included pulmonary blastomycosis (a pulmonary disease caused by inhaling spores of the dimorphic fungus blastomyces dermatitidis which can cause cough, fever, and non-healing skin lesions), viral hepatitis C (a virus that attacks the liver and leads to inflammation). R19's admission MDS assessment dated [DATE], indicated R19 was cognitively intact, had no rejections of care, and required extensive to total assistance with activities of daily living which included personal hygiene and toilet use. In addition, R19's MDS indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to follow a self-administration of medication assessment and left medication in the room for 1 of 1 (R9) resident reviewed for self-administration of medication. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had moderate cognitive impairment. Diagnoses included Parkinson's, epilepsy, depression, major depressive disorder, disorientation and Delirium. R9 had delusions and hallucinations. The Care Area Assessment Summary (CAA)-Focus areas to provide specialized, resident specific care, included Delirium, cognitive loss/dementia, psychosocial well-being and psychotropic drug use. R9's care plan undated, indicated cognitive impairment and behaviors. During an observation on 7/31/23 at 3:43 p.m., on R9's dresser included a bottle of saline nasal spray. A follow up observation on 8/3/23 at 8:05 a.m., the saline nasal spray remained on R9's dresser. R9's Medication Self Administration Assessment (SAM) form dated 5/15/23, indicated R9 was not safe to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the grab bar was secured appropriately to accommodate needs and promote independence with bed mobility for 1 of 1 resident (R6) who had concerns about a loose grab bar . Findings include: R6's Resident Face Sheet, indicated R6 had diagnoses of diabetes mellitus, malignant neoplasm of right renal pelvis and bladder, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), muscle weakness, morbid obesity, anxiety, osteoarthritis of left shoulder, and depression. R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 was severely cognitively impaired and required extensive assistance with activities of daily living, bed mobility, and transfers. In addition, R6 had no rejections of care. R6's care plan modified on 6/15/23, indicated R6 required assistance with bed repositioning. Interventions included boost in bed as needed, dependent on two staff to reposition when in bed, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure conflicting directives for emergency care and treatment were clarified to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 1 residents (R53) reviewed for advanced directives. Finding include: R53's Resident Face Sheet, indicated R53 had diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, cognitive communication deficit, and abnormalities of gait and mobility. R53's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R53 was severely cognitively impaired. R53's Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], indicated the following: Section A: Attempt Resuscitation / CPR (Note: selecting this requires selecting Full Treatment in Section B). Hand written in the document was, Chest Compression Only NO INTUBATION Section B: Full treatment. Use…

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 provide a written bed hold to resident and or family for 1 of 1 resident (R28) who was transferred to the hospital for medical evaluation. Findings include: R28's significant change minimum data set (MDS) assessment dated [DATE], indicated R28 was cognitively intact. R28's diagnoses included: Chronic obstructive pulmonary disease and heart disease. R28's medical record lacked a bed hold was completed when R28 transferred out of the facility on 4/9/23 for a medical evaluation. On 8/2/23 at 12:47 p.m., R28 stated when she left the facility, she never received or had to sign any paper about her bed being held at the facility for her. On 8/3/23 at 4:35 p.m., the assistant director of nursing (ADON) confirmed she did not have a bed hold document for 4/9/23 and that the EMR and the paper chart did not show evidence a bed hold was reviewed and completed with R28. The ADON stated she had called the nurse on that shift and the nurse had told her she had…

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 observation, interview and document review the facility failed to provide timely assistance with toileting for 1 of 2 (R6) residents who required staff assistance with toileting. Findings include: R6's Face Sheet, indicated R6 had diagnoses which included diabetes mellitus, malignant neoplasm of right renal pelvis and bladder, muscle weakness, depression, morbid obesity, and constipation. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R6 was severely cognitively impaired, usually would understand and was usually understood. R6 had no rejections of care. In addition, R6 required extensive assistance with toilet use and was always continent of bowel and bladder. R6's care plan modified on 6/15/23, indicated R6 was continent of bowel and bladder, his goal was to remain continent of both. Interventions included staff to remind and assist R6 to the toilet upon rising, every two to three hours during the day and at bedtime. During an interview on 8/1/23 at 2:37 p.m., R6 stated he would…

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 observation, interview and document review, the facility failed to provide timely assistance with repositioning to prevent the worsening or development of pressure ulcers for 1 of 3 (R19) reviewed pressure ulcers. Findings include: R19's Face Sheet, indicated R19 had diagnoses which included pulmonary blastomycosis (a pulmonary disease caused by inhaling spores of the dimorphic fungus blastomyces dermatitidis which can cause cough, fever, and non-healing skin lesions). R19's admission MDS assessment dated [DATE], indicated R19 was cognitively intact, had no rejections of care, and required extensive to total assistance with activities of daily living which included personal hygiene and toilet use. In addition, R19's MDS indicated he was incontinent of bowel, was at risk for pressure ulcers and had seven pressure ulcers on admission to the facility. R19's care plan dated 6/20/23, indicated willingness to be repositioned according to plan. Interventions included repositioning every two hours and reposition…

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 restorative therapy services were completed for 2 of 2 (R32, R28) residents evaluated for range of motion. Findings include: 32's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R32 had moderate cognitive impairment. R32 required extensive assistance for locomotion on and off the unit. Diagnoses included Stroke, heart failure and hemiplegia/hemiparesis-weakness or paralysis to one side of the body. R32's Care Area Assessment indicated Cognitive loss/dementia and falls as specialized areas of care R32 needed addressed. Restorative orders dated 11/22, copy hung on R32's closet door, indicated R32 was contact guard assist with front wheel walker (FWW). R32 was to be walked twice a day with assistance from staff. R32's care plan lacked indication R32 was on a daily restorative program. R32's Restorative therapy documentation from 11/1/22, to 8/3/23, was reviewed and indicated R32 lacked documentation of any restorative program…

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 staffing was available in order to ensure appropriate and timely care was given to 3 of 3 residents (R 6, R28, R32) who were to received range of motion, and provide timely assistance with toileting. Finding include: See F677: The facility failed to provide timely assistance with toileting for 1 of 2 (R6) residents who required staff assistance with toileting. During an interview on 8/1/23 at 2:25 p.m., nursing assistant (NA)-E stated she was taking care of eight residents. NA-E stated sometimes it would be one NA for 19 residents and then it would be difficult to get cares completed. On days with one staff for 19 resident's showers would not get done. Checks and changes would be done but they might be late. During an interview on 8/1/23 at 2:37 p.m., R6 stated he would use his call light and no one would come to answer it and then he would have a bladder accident. During an interview on 8/3/23 at 8:40 a.m., R6 stated…

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's room was free from urine odors for 2 of 21 residents (R53, R12) whose rooms were reviewed for odors. Findings include: R53's Resident Face Sheet no date, indicated R53 had diagnoses which included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, cognitive communication deficit, and abnormalities of gait and mobility. R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 was severely cognitively impaired and was dependent on staff for personal hygiene and toilet use. In addition, R53's MDS indicated R53 was always incontinent of bowel and bladder. R53's care plan activated on 1/28/22, indicated R53 was always incontinent of bladder and was totally dependent on staff for all toileting needs. Interventions included check and change every two hours, provide pericare after each incontinent episode,…

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.