Good Samaritan Society - Inver Grove Heights

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 completed for 1 of 3 residents (R1). Additionally, the facility failed to secure a leg bath for a catheter off the floor for 1 of 1 resident (R2) reviewed for infection control. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had an indwelling catheter, an ostomy (a surgically created opening in the abdomen that allows waste to exit the body), a feeding tube, and was dependent upon staff for all activities of daily living (ADLs). Identified R1 had diagnoses that included traumatic spinal cord dysfunction, a neurogenic bladder (loss of bladder function due to a nerve problem), and quadriplegia. R1's care plan dated 8/26/24, indicated R1 had an indwelling foley catheter, a feeding tube, and indicated enhanced barrier precautions (EBP) (measures intended to prevent the spread of multi-drug-resistant organisms) was in place related to wounds and an…

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 final cooking temperatures were checked or obtained in a manner to reduce the risk of cross-contamination between food items prepared in the main production kitchen. This had potential to affect all 36 residents who were served the meal. Findings include: On 12/10/24 at 11:36 a.m., food production in the main kitchen was observed with cook (CK)-A present. CK-A placed a metallic tray filled with breadsticks into the oven and pulled out a pan which had two, foil pans on top with lasagna in them. CK-A used a spike-style thermometer to pierce the seal over the lasagna and obtain a temperature which read, 182 [F]. CK-A then turned and stated aloud to the food and nutrition service manager (FNM) they were looking for a wipe to clean the probe of the thermometer. FNM left the kitchen and returned with a white-colored box labeled, Ecolab Probe Wipes, and placed them on the elevated counter. The counter space contained another box of these wipes hidden amongst some spices and paper, along with several loose…

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 opportunity for 4 of 4 residents (R22, R31, R1, R15) reviewed to participate in care planning and care conferences. Findings include: R22 R22's significant change Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition. R22's medical record was reviewed from 2/10/24 to 12/11/24 and lacked evidence that R22's representative was invited or attended a care conference held during this period. During an interview on 12/10/24 at 2:30 p.m., R22's resident representative (FM)-A stated she was the one who would attend R22's care conferences but she had not been invited to one since 10/23. FM-A stated she would have wanted to participate in a care conference, but none had been offered since last year. R31 R31's quarterly MDS dated [DATE], indicated R31 had intact cognition. R31's medical record was reviewed from 6/10/24 to 12/11/24 and lacked evidence that R31 or her representative was invited or attended a care conference held…

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 immediately report incidents of potential staff to resident abuse to the state agency (SA) within two hours, as required for 1 of 3 residents (R29) reviewed for abuse. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no delusional behaviors or hallucinations. R29's care plan dated 7/18/24, indicated R29 had a history of paranoia, accusations against staff, only allowing certain staff to work with her, and manipulating situations and staff. The care plan included goals for R29 of not displaying symptoms such as paranoia, yelling and swearing at staff, refusing care, accusing staff, and manipulation. The care plan included interventions such as using approaches with R29 to maximize involvement in daily decision-making and activity, stopping care and returning if R29 becomes agitated, and providing care in pairs for staff and resident safety. The care plan did not indicate what accusations…

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 voiced complaints of potential abuse were acted upon, and investigated to ensure an adequate protection plan was provided to ensure freedom from abuse for 1 of 3 residents (R29) reviewed for abuse and neglect. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no delusional behaviors or hallucinations. R29's care plan dated 7/18/24, indicated R29 had a history of paranoia, accusations against staff, only allowing certain staff to work with her, and manipulating situations and staff. The care plan included goals for R29 of not displaying symptoms such as paranoia, yelling and swearing at staff, refusing care, accusing staff, and manipulation. The care plan included interventions such as using approaches with R29 to maximize involvement in daily decision-making and activity, stopping care and returning if R29 becomes agitated, and providing care in pairs for staff and resident safety.…

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 a baseline care plan for smoking for 1 of 1 residents (R189) reviewed who smoked. Findings include: During an interview on 12/10/24, at 11:57 a.m., R189 indicated he smoked cigarettes and was made aware after admission the facility was a non-smoking facility. R189 stated he has gone outside the building to smoke while being a resident. R189 indicated staff has told him a few different things about smoking which included: must go on the other side of the parking lot to smoke, can't let people see me smoking and just tell people I am going for a walk. R189 stated the staff at the front desk told him, that as long as she couldn't see me, I could go for a long walk [to smoke]. R189 indicated that over the weekend, one of the nurses sat by the front window and watched me smoke outside. R189 further indicated the head of nursing came and told me today that I can't smoke here and indicated no staff have discussed or offered any nicotine replacement…

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 routine personal care (i.e., bathing, nail care) were provided for 1 of 3 residents (R11) reviewed for activities of daily living (ADL's). Findings include: R11's admission Minimum Data Set (MDS) assessment, dated 9/11/24, indicated R11 had intact cognition with no hallucinations or delusions, no behaviors or no rejection of care. MDS assessment indicated R11 required maximal staff assistance for bathing and moderate assistance with personal hygiene. Diagnoses included: diabetes (disease that results in too much sugar in the blood), Alzheimer's disease (progressive disease that affects memory and other mental functions), and epilepsy (abnormal electrical brain activity that causes seizures). R11's care plan, printed 12/12/24, identified R11 has an ADL [activity of daily living] self-care performance deficit with the following interventions: -BATHING: Resident requires 1 staff for bathing. Prefers two baths/showers per week. -ORAL…

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 vision needs were met for 1 of 1 residents (R31) reviewed for missing eye glasses. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 was diagnosed with dementia and required set-up help with dressing. The MDS indicated R31 had adequate vision and used corrective lenses. R31's admission assessment dated [DATE], indicated R31 had adequate ability to see in adequate light (with glasses or other visual appliances) and utilized corrective lenses. R31's care plan dated 2/22/24, indicated R31 had impaired cognition, impaired decision making, short-term memory loss, and scored an 8/30 on the St. Louis University Status Examination (SLUMS, test to determine neurocognitive disorder/dementia) indicating dementia. R31's care plan indicated she needed the assistance of one person for dressing and grooming and had a history of falls. The care plan did not include R31's need for corrective lenses but did…

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 assistance with repositioning for 1 of 1 residents (R22) with a history of pressure ulcers. Findings include: R22's significant change Minimum Data Set (MDS) dated [DATE], indicated R22 had severely impaired cognition and was diagnosed with kidney disease, diabetes, and dementia. The MDS indicated R22 was dependent on staff for bed mobility and was receiving hospice care. The MDS indicated R22 was at risk of developing pressure ulcers. R22's provider progress note dated 11/26/24, indicated R22 had a pressure injury on her right shoulder, impaired skin integrity, limited mobility, and muscle weakness. The note indicated R22 was predisposed to pressure injuries due to weakness and inability to reposition herself. The provider encouraged staff to offload and reposition [R22] as much as possible. R22's Order Summary Report dated 12/5/24, indicated nursing staff were to turn and reposition R22 every two to three hours 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 provide appropriate side effect monitoring of psychotropic medication consumption for 1 of 5 residents (R26) reviewed for unnecessary medication use. Findings include: R26's admission Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact, needed setup for oral hygiene and eating, needed moderate assistance with upper body dressing and was dependent with bathing, lower body dressing, personal hygiene, and toileting. The MDS included diagnoses of fractures and other multiple traumas, atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart) , hypertension (high blood pressure), renal insufficiency (poor function of the kidneys), hyperlipidemia (high levels of fat particles in the blood), thyroid disorder (thyroid gland dysfunction), arthritis (swelling and tenderness in one or more joints), depression, and glaucoma (a condition that damages the optic nerve that causes vision loss and blindness). R26'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 notify the physician directly and immediately regarding changes in lower extremity movement for 1 of 3 residents (R1) reviewed for change of condition, additionally nurse practitioner failed to notify the medical doctor regarding change of condition concerns brought to her attention by her nurse. Findings include: R1's Face Sheet identified R1 had diagnoses of spinal stenosis. R1's care plan dated 10/17/23, identified R1 had mobility deficits due to spinal stenosis and required one staff with maximum assistance for toilet use, one staff for bed mobility and dressing. R1 required assist of one staff to stand pivot to the wheelchair. During interview on 10/30/23 at 10:55 a.m.,R1 recalled a situation in therapy on a Friday (10/20/22) when she was being transferred and experienced a sudden onset of intense pain in her back, it felt like electrodes all over the body. R1 indicated she yelled out at the time. R1 did not recall if a nurse evaluated her…

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 (R135) who utilized a urinary catheter. Findings include: R135's medical diagnoses from her electronic medical record (EMR) downloaded 10/3/23, indicated an admission date of 9/26/23. R135's diagnoses include osteomyelitis of vertebra, sacral and sacrococcygeal region (infections of the bones of spine), Stage 4 pressure ulcer to sacral region, Stage 4 pressure ulcer to right buttock, Stage 4 pressure ulcer to left upper back, quadriplegia (paralysis), epilepsy, neuromuscular dysfunction of bladder (bladder's muscles and nerves are not communicate properly with the brain), neurogenic bowel (loss of normal bowel function), depression, colostomy (opening in the abdomen for stool to exit the body), gastrostomy (feeding tube inserted in the abdomen and used to supply nutrition to the stomach), and anxiety. R135's care plan printed 10/2/23, failed to mention a foley catheter care. R135'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 care plan to ensure competency and safety with self-administration of medication for 1 of 1 resident (R26) observed to be storing and self-administering medication in their room. Findings include: R26's most recent quarterly Minimum Data Set (MDS), dated [DATE], identified R26 had intact cognition. On 10/2/23 at 8:16 a.m., R26 was observed laying in his bed. R26 had a bedside table positioned immediately next to his bed and within his reach and, on top of the table, there was a white-colored bottle of nasal spray sitting on the bedside table with a commercial label indicating it was a medicated spray (i.e., Triamcinolone Acetonide). The bottle lacked a pharmacy label. When interviewed at this time, R26 stated he used the nasal spray for a long time when he needed it adding the staff did not assist him with it. In addition, on the bedside shelf there were multiple, opened bottles of Debrox (carbamide peroxide)…

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 resuscitation wishes were updated in the electronic medical record (EMR) based on a signed Physician Orders for Life Sustaining Treatment (POLST, a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest) for 1 of 1 residents (R23) reviewed for advanced directives. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 had moderately impaired cognition with diagnoses including hypertension, diabetes, dementia, and chronic obstructive pulmonary disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness). R23 required extensive assistance for bed mobility, transferring, dressing, and toilet use. R23's order summary on [DATE], included a Do Not Resuscitate (DNR) order dated [DATE], indicating R23 would not receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. R23's POLST dated [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 interview and document review, the facility failed to accurately complete the comprehensive assessment of a resident's needs, strengths, goals, life history and preferences to determine a resident's functional capacity. In addition, the facility failed to ensure cognitive mood and needs were completed for 1 of 1 residents (R285) reviewed for assessment accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2017, identified the MDS as an assessment tool which facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. Further, the manual provided instructions to ensure accurate and complete coding for each section of the assessment as follows: Section C: Cognitive Patterns, with a written intent of determining the residents attention, orientation and ability to register and recall new…

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 complete quarterly Minimum Data Set (MDS) in a complete, accurate manner to ensure cognitive, mood, and bowel and bladder statuses were evaluated for 4 of 4 residents (R8, R10, R27, R30) reviewed for assessment accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2017, identified the MDS as an assessment tool which facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. Further, the manual provided instructions to ensure accurate and complete coding for each section of the assessment as follows: Section C: Cognitive Patterns, with a written intent of determining the residents attention, orientation and ability to register and recall new information. These items were listed as crucial factors in many care planning decisions.…

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 incomplete Level I Pre-admission Screening and Resident Review (PASARR) was conducted for 1 of 1 (R2); and failed to ensure a Level II PASARR was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 2 of 2 residents (R4, R11) reviewed for PASARR. Findings include: R2 R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted to facility on 3/6/21. In addition, R2 was unable to complete the cognitive portion of assessment, required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toileting, and personal hygiene. In addition, listed R2 with several diagnoses including Parkinson's disease (a chronic degenerative disorder of the central nervous system), depression, and schizophrenia (a mental disorder characterized by continuous or relapsing episodes of psychosis). R2's entire medical record was reviewed and lacked documentation an…

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 timeliness of person-centered care conferences for 1 of 1 resident (R11) to include review and revision of the care plan by an interdisciplinary team and the resident. Findings include: R11's significant change Minimum Data Set (MDS), dated [DATE], indicated R11 was admitted to the facility on [DATE], was cognitively intact, independent with ambulation and required supervision with most activities of daily living (ADLs) to include bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. R11's diagnoses, printed on 10/4/23, indicated R11 had several medical diagnoses including a primary diagnosis of chronic obstructive pulmonary disease (also called COPD, group of lung diseases that block airflow and make it difficult to breathe) and other diagnoses of congestive heart failure (also called CHF, a chronic condition in which the heart doesn't pump blood as well as it should with symptoms such as shortness of breath, fatigue,…

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 general daily grooming tasks, including shaving, for one of one resident (R4) observed with facial hair. Findings include: R4's quarterly Minimum Data Set (MDS), dated [DATE], indicated R4 was admitted to the facility on [DATE], had moderate cognitive impairment and required supervision with most activities of daily living (ADLs) and extensive assistance with toileting. R4's Medical Diagnoses list, dated 3/31/23, indicated R4 had several medical diagnoses including a primary diagnosis of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and a secondary diagnosis of schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion) and chronic obstructive pulmonary disease (a common lung…

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 properly care plan for and monitor a wound VAC (vacuum-assisted closure of a wound is a type of therapy to help wounds heal and is also known as wound VAC) for 1 of 1 resident reviewed for quality of care. In addition, the facility failed to comprehensively assess, and create and implement interventions for a new, non-pressure related skin injury for 1 of 1 residents (R23) reviewed for wounds. In addition, the facility failed to perform neurological evaluations on a resident following a fall with a head strike and subsequent change in mentation for 1 of 1 residents (R26) reviewed. Findings include: Wound VAC R186's entry Minimum Data Set (MDS), dated [DATE], indicated R186 was admitted to the facility on [DATE]. R186 did not have cognitive scoring in her MDS but appeared alert and oriented during interview. R186's entire medical record, including physician orders, care plan, and medication and treatment record lacked orders and direction…

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 assistance with repositioning for 1 of 1 (R135) who was at risk for pressure ulcers. Findings include: R135's medical diagnoses from her electronic medical record (EMR) downloaded 10/3/23, indicated an admission date of 9/26/23. R135's diagnoses included osteomyelitis of vertebra, sacral and sacrococcygeal region (infections of the bones of spine), Stage 4 pressure ulcer (full skin thickness) to sacral (tailbone) region, Stage 4 pressure ulcer to right buttock, Stage 4 pressure ulcer to left upper back, quadriplegia (paralysis), epilepsy, neuromuscular dysfunction of bladder (bladder's muscles and nerves are not communicate properly with the brain), neurogenic bowel (loss of normal bowel function), depression, colostomy (opening in the abdomen for stool to exit the body), gastrostomy (feeding tube inserted in the abdomen and used to supply nutrition to the stomach), and anxiety. R135's care plan dated 9/27/23, 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 observation, interview and document review, the facility failed to ensure oxygen orders were received and tubing was changed and dated timely for 1 of 1 resident (R11) reviewed for respiratory care. Furthermore, the facility failed to create a comprehensive plan of care for oxygen therapy for 1 of 1 resident (R11) reviewed for respiratory care. Findings include: R11's significant change Minimum Data Set (MDS), dated [DATE], indicated R11 was cognitively intact, was independent with ambulation and required supervision with most activities of daily living (ADLs) to include bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS further indicated R11 was not admitted with oxygen but was currently using oxygen. R11's diagnoses, printed on 10/4/23, indicated R11 had several medical diagnoses including a primary diagnosis of chronic obstructive pulmonary disease (also called COPD, group of lung diseases that block airflow and make it difficult to breathe) and other diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review the facility failed to assess and monitor for complications per standard of practice before and after dialysis for 1 of 1 resident (R29) reviewed for dialysis care. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was admitted to facility on 3/23/23 and had intact cognition and required supervision with activities of daily living (ADL's). R29's diagnoses included end stage renal disease, anemia, diabetes, and depression. In addition, R29 received dialysis. R29's provider orders downloaded from electronic medical record on 10/2/23, failed to indicate dialysis site care and assessment before and after dialysis sessions. R29's care plan printed 3/30/23 indicated a focus of The resident needs hemodialysis R/T [related to] Renal failure and an intervention initiated on 5/3/23 which indicated, Monitor/document/report to health care provider PRN for s/s of renal insufficiency: changes in level of consciousness, changes in skin…

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 non-pharmacological interventions were attempted and recorded prior to administration of as-needed (PRN) narcotic medication to reduce the risk of potential complications for 1 of 1 residents (R30) reviewed for unnecessary medication use. Findings include: R8's significant change Minimum Data Set (MDS) dated [DATE], indicated R30 had intact cognition. R8's significant change MDS dated [DATE], indicated R30 had diagnoses including hypertension, a hip fracture, and a stroke. The pain assessment indicated R30 frequently had severe activity-limiting pain and required extensive assistance for bed mobility, transferring, and dressing. The MDS lacked documentation related to R30's cognition. R30's care plan dated 9/8/23, lacked interventions related to R30's pain. R30's Order Summary Report dated 10/1/23, indicated R30 received: two milligrams (mg) of oral hydromorphone (a narcotic pain medication) every eight hours as needed. The order also…

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 appropriate side effect monitoring was completed, in accordance with the care plan and standard of care, related to antipsychotic medication use despite an increase in abnormal involuntary movement scoring for 1 of 5 residents (R14) reviewed for unnecessary medications. Findings include: A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension [which can] lead to dizziness, syncope, falls. It should be evaluated by both historical and routine measurement. R11's significant change Minimum Data Set (MDS), dated [DATE], indicated R11 was admitted to the facility on [DATE], was cognitively intact, independent with ambulation and required supervision with most activities of daily living (ADLs) 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 record review, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Two medication administration errors occurred out of 27 opportunities resulting in a 7.41 % medication error rate for 1 of 5 residents (R8) observed during medication pass. Findings include: Mayo Clinic article dated 2/1/23, Blood Sugar Testing: Why, When and How, indicated blood sugar testing results may be used to monitor the effectiveness of diabetes medications and understand how diet, exercise, and other factors effect blood sugar levels. The article indicated blood sugar testing should be completed before meals and at bedtime if daily insulin injections were used. Novolog Insulin Aspart Prescribing Information dated 2/23, indicated insulin aspart (a fast-acting insulin that begins to work 15 minutes after injection and reaches peak effect after one hour) should be administered five to ten minutes prior to a meal. R8's significant change Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure standard infection control practices were in place during administration of intramuscular (IM) seasonal flu injection for 1 of 1 (R135) observed for injection practices. In addition, facility failed to ensure contaminated lancets for 1 of 1 (R11) were secured in a sharps container. Findings include: R135's medical diagnoses from the electronic medical record (EMR) downloaded 10/3/23, indicated an admission date of 9/26/23. R135's diagnoses include osteomyelitis of vertebra, sacral and sacrococcygeal region (infections of the bones of spine), Stage 4 pressure ulcer to sacral region, Stage 4 pressure ulcer to right buttock, Stage 4 pressure ulcer to left upper back, quadriplegia (paralysis), epilepsy, neuromuscular dysfunction of bladder (bladder's muscles and nerves are not communicate properly with the brain), neurogenic bowel (loss of normal bowel function), depression, colostomy (opening in the abdomen for stool to exit the body), gastrostomy…

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.