Green Lea Senior Living

Based on interview and document review, the facility failed to ensure the services of a registered nurse (RN) onsite for 8 consecutive hours/7 days a week. This had the potential to affect all residents who resided at the facility. Findings include: The payroll based journal (PBJ) staffing report for quarter 2 of 2025 (January 1-March 31) indicated no RN hours reported for the following days : 1/02 (TH), 1/03 (FR), 1/04 (SA), 1/05 (SU), 1/09 (TH), 1/18 (SA), 1/19 (SU), 2/02 (SU), 2/16 (SU), 3/1 (SA), 3/02 (SU), 3/15 (SA), 3/16 (SU), 3/29 (SA), 3/30 (SU). Review of facility payroll and staffing schedules indicated 4 hours of RN coverage on 1/4/2025 and no RN coverage for 1/05, 1/18, 1/19, 2/02, 2/16, 3/01, 3/02, 3/15, 3/16, 3/29, and 3/30. During interview on 6/3/25 at approximately 3 p.m., the regional nurse consultant confirmed there was no RN coverage for the indicated dates and confirmed it is an expectation to have an RN in the building 8 consecutive hours a day/ 7 days a week. During an interview on 6/5/25 at 12:17 p.m., the assistant director of nursing (ADON) stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain respect and dignity for personal possessions for 1 of 2 residents (R28) reviewed who had his room searched and items removed without consent. Findings include: R28's quarterly Minimum Data Set (MDS) assessment dated [DATE] included no cognitive impairment. Furthermore, his mood assessment indicated he rarely socially isolated. R28 is independent with eating, oral hygiene, toileting, dressing, and repositioning. R28 required minimal cueing for showering/bathing. During interview on 6/03/25 at 11:20 a.m., R28 stated the previous administrator at the facility entered his room without his permission and searched his room, the administrator told him they were searching his room because they thought he was making moonshine with orange peels and water or mouthwash. They also confiscated his vape pens and won't give them back. R28 added the administrator came into his room without consent and removed multiple cups and dishes. R28 said 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 Based on observation, interview, and record review, the facility failed to accommodate bathing/showering preferences for 1 of 1 resident (R1) reviewed for choices. Finding include: R1's admission Minimum Data Set (MDS) assessment dated [DATE] identified admission to the facility on 4/30/25, had intact cognition. R1 required substantial/maximal assistance from facility staff for shower/bathing. R1's care plan dated 5/7/25 contained only one item; R1 had a potential nutritional deficit related to Parkinson's, dementia, chronic pain and depression. The care plan lacked personal preference for showering/bathing preferences. During observation and interview on 6/3/25 at 11:05 a.m., R1 stated he preferred to have showers/baths on Monday, Wednesday, and Friday (M/W/F). R1 stated he rarely gets 3 showers/baths as he prefers; usually getting showers/baths 2 days per week; Tuesdays and Fridays. During interview on 6/4/25 at 10:34 a.m., R1 stated he told the facility when he was admitted he preferred showering/bathing on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a person-centered care plan for 2 of 2 residents (R19, R1) reviewed for care planning. Findings include: R19 R19's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R19 was cognitively intact with no behaviors. R19 had limited range of motion to one lower extremity, supervision with eating and oral cares, partial moderate assistance for toileting hygiene and bathing and lower body dressing, and supervision with bed mobility. The MDS indicated R19 was frequently incontinent of urine and bowel and had multiple medical conditions including: atrial fibrillation (abnormal rhythm of the heart), heart failure, hypertension (high blood pressure), peripheral vascular disease (impaired blood flow to extremities), renal insufficiency (impaired kidney function), diabetes, anxiety, and schizophrenia (mental health diagnosis), R19's admission MDS also indicated R19 had a history of falls prior to admission. The MDS indicated R19 received…

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

Based on observation, interview, and record review the facility failed to keep 2 of 2 mechanical lifts in proper working condition. Findings include: During an observation on 9/5/24 at 9:41 a.m., nursing assistant (NA)-A was observed with Volara brand mechanical sit-to-stand lift (used to assist a resident to different positions with the resident needing to provide half of the weight bearing status) identified by the label B01-18. The lift had handle bar up and down switches that when pressed did not work to raise the resident up into a standing position. The same lift had a remote with an up and down function and the button to lower a resident to a sitting position was non-functioning. All of the machine wheels were visibly caked with hair that prevented the machine to easily turn or push. A full body mechanical lift A02-16 had a remote with the two buttons hanging out of the secure button holder held together by electrical tape. The wheels of this lift were also caked with hair. During an interview on 9/5/24 at 9:41 a.m., NA-A stated both of the lifts were still in use even though…

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 Facility Assessment identified the facility's staffing needs based on the care needs of the resident population. This had the potential to affect all 32 residents who resided in the facility. Findings include: Refer to F688. The Facility assessment dated [DATE], included a Purpose Statement, The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. It further identified the assessment would address staffing needs and noted This facility assessment will be used to: Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care; Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ambulation program was provided to maintain mobility to reduce the risk for falls as ordered by physical therapy for 1 of 1 resident (R2) who had a history of falls. Findings include: R2's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had intact cognition, no rejection of care, was independent with toileting hygiene, required partial assistance with showering, personal hygiene, was independent with bed mobility, utilized a walker and wheelchair, and walking was listed as not applicable. Diagnoses included heart failure, arthritis, and kidney failure. R2's care plan revised 8/9/24, indicated R2 had limited physical mobility with fall risk r/t disease process, functional loss, and history of falls on 2/18/24, 3/14/24, 4/2/24, and 7/24. Interventions per therapy recommendation dated 3/8/24, included patient ambulation 3x/day with use of 2WW (two wheeled walker) and CGA (contact guard assistance) with…

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

Based on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R1) reviewed for medical record accuracy. Findings include: R1's provider orders included a treatment order dated 5/8/24, directing staff to complete a Body Audit assessment weekly one time a day every Friday. R1's treatment administration record (TAR) included the Body Audit assessment order scheduled on Fridays. R1's TAR dated 7/1/24 to 7/31/24, included charting of the Body Audit assessment as completed on 7/5/24, 7/12/24, 7/19/24, and 7/26/24. R1's TAR dated 8/1/24 to 8/31/24, included charting of the Body Audit assessment as completed on 8/2/24 and not completed on 8/9/24. Review of R1's electronic health record (EHR), identified Body Audit assessments dated 7/5/24, and 7/12/24. R1's EHR lacked records of the Body Audit assessments charted as completed on 7/19/24, 7/26/24, and 8/2/24. In an interview on 8/13/24 at 12:25 p.m., licensed practical nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control procedures were followed for 2 of 2 residents (R3 and R4) when staff failed to follow enhanced barrier precautions (EBP) while providing cares and treatment. Findings include: R3's face sheet printed 8/14/24, indicated diagnoses of pressure ulcer of right buttock stage 4 and chronic kidney disease. R3's quarterly Minimum Data Set (MDS) assessment indicated R3 had severe cognitive impairment, lower extremity impairment on both sides, use of a wheelchair, dependent on staff for toileting hygiene, bathing, lower body dressing, and substantial assistance for personal hygiene, and indwelling bladder catheter. R3's care plan revised 3/25/23, indicated a self-care performance deficit r/t (related to) right buttock pressure ulcer and two staff assistance for transfers with use of a standing mechanical lift. R3's care plan revised 6/19/24, also indicated the presence of an indwelling foley catheter with a goal of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of 5 residents (R21, R26, R7) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series (pneumonia vaccine) as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Furthermore, the facility failed to ensure the influenza vaccination (flu vaccine) was offered 2 of 5 residents (R7, R11) reviewed for vaccinations. Findings include: The Center for Disease Control and Prevention identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R21's quarterly (MDS) assessment dated [DATE], 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 record review, and interview the facility failed to provide a written notification/copy of a bed hold for 1 of 3 residents (R5) reviewed for hospitalization. Findings include: R5's quarterly minimum data set (MDS) assessment dated [DATE], indicated R5's diagnoses included hypothyroidism, traumatic brain injury, convulsions, chronic kidney disease, cardiac murmur, dementia, hypertension, R5's progress notes indicated R5 became nauseous with emesis on 8/30/24. After brief monitoring at facility, doctor ordered resident to emergency room (ER) for further examination the same day. Progress notes further indicated facility staff attempted to contact resident's representative regarding bed hold form but was unable to speak with them via phone, with no option to leave a message. Progress note further indicated facility would send a copy of bed hold policy to representative via the mail. Resident was hospitalized from [DATE] until 9/07/23. Resident was discharged from hospital back to facility. R5's medical…

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

Based on observation, interview, and record review the facility failed to provide facial grooming for 1 of 2 residents (R24) reviewed for activities of daily living (ADL's) for residents who are dependent on staff for their care. Findings include: R24's annual Minimum Data Set (MDS) assessment, dated 2/2/2024, indicated R24 has severe cognitive impairment with no behaviors or rejection of care. Furthermore, R24 MDS included R24 is dependent on staff to perform all personal hygiene tasks, including facial grooming. R24's diagnosis include, dementia without behavioral, mood, psychotic disturbances and anxiety. R24's care plan, identified R24 having an ADL self-care performance deficit with a goal of being dressed and groomed according to personal preference on a daily basis, directs staff to provide personal hygiene and grooming daily and as needed (PRN). R24's bathing record reviewed from 4/5/2024 through 4/14/2024, indicated R24 required substantial to dependent assistance with bathing. R24's personal hygiene record review from 3/19/2024 through 4/17/2024, indicated R24 required…

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 offer the COVID-19 (C-19) vaccine to a resident eligible to receive the vaccine for 1 of 5 residents (R7) reviewed for immunizations. Findings include: R7's admission Minimal Data Set (MDS) assessment dated [DATE], indicated R7 cognition moderately impaired with diagnosis of medically complex conditions, diabetes mellitus, and a pulmonary disease (lung disease). MDS indicated that R7 had been admitted on [DATE]. Facility provided document, titled, Minnesota Immunization information correction (MIIC), indicated R7 had not received any of the C-19 vaccination series. During an interview on 4/17/24 at 1:06 p.m., the infection preventionist (IP) stated during the admission process individuals are reviewed for vaccination status. IP stated she would follow-up and review the C-19 vaccination status as well. IP stated she was not sure why the R7's record failed to show a history or offering of the C-19 vaccination and it should be offered with a consent 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 ensure physician notification of skin injury that required treatment for 1 of 3 residents (R1) reviewed for pressure ulcers. The findings include: R1's face sheet printed 3/25/24, included diagnoses of chronic right heart failure, acute respiratory failure, type 2 diabetes mellitus with diabetic polyneuropathy (a type of nerve damage that can occur if you have diabetes. High blood sugar [glucose] can injure nerves throughout the body.), type 2 diabetes mellitus with foot ulcer, pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone) stage 2, non-pressure ulcer of other part of right foot with fat layer exposed. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, R1 was at risk for pressure ulcers, had one unhealed stage 2 pressure ulcer (partial thickness loss of dermis [The inner layer of the two main layers of the skin] presenting as a shallow open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to revise the care plan that addressed goals and interventions for new diagnoses of nonthrombocytopenic pupura for 1 of 1 resident (R2) who developed substantial bruising. Findings include R2's admission record indicated R2 had diagnoses that included chronic pain and other nonthrombocytopenic purpura (purple, red, or yellowish-brown spots or patches develop under the skin due to inflammation, damaged blood vessels, or an underlying health condition). R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment, was independent with oral hygiene and eating, and was dependent with toileting, dressing, personal hygiene, and mobility. R2 was at risk for pressure ulcers and no other skin problems identified. R2's care plan dated 4/6/23, included R2 has a potential for impairment to skin integrity related to immobility, and incontinence. Interventions included: keep skin clean and dry. Observe skin during cares. Report…

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 complete pressure ulcer risk assessment, failed to comprehensively assess and monitor pressure ulcers, notify physician, and follow physician orders to prevent and/or mitigate the risk of new ulcer development or deterioration for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Unstageable Pressure Ulcer: Full-thickness skin and tissue…

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 secure a narcotic medication which was delivered without a corresponding medication order, and facility failed to investigate circumstances surrounding lost narcotic and implement action plan to prevent potential reoccurrence for 1 of 1 resident (R1) reviewed for drug diversion. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated an intact cognition. The MDS indicated R1 had occasional mild pain and received scheduled pain medication. The progress notes showed on 8/26/23, R1 rated hip pain at 10/10 despite oral medication and topical application of ice pack to area. The progress notes indicated R1 was transported to the hospital's emergency department at 4:30 p.m. and returned at 9:30 p.m., with an order for hydrocodone-acetaminophen 5-325 milligrams (mg) 1 tablet every six hours as needed for pain times three days. The progress notes further indicated the order for hydrocodone was sent to pharmacy. However, the progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility did not report allegation of drug diversion in a timely manner for 1 of 1 resident (R1) reviewed for medication management. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated an intact cognition. The MDS indicated R1 had occasional mild pain and received scheduled pain medication. The progress notes dated 8/26/23, indicated R1 requested to be sent to the emergency department (ED) related to hip pain, which she rated at 10/10. The ED visit summary notes dated 8/26/23, indicated an order for R1 to start hydrocodone-acetaminophen 5-325 milligram (mg), also known as Norco, one tablet every six hours as needed for pain times three days. However, the pharmacy packing slip dated 8/28/23, indicated pharmacy delivered to the facility and registered nurse (RN)-A received 10 tablets of 5 mg oxycodone for R1 instead of Norco. During interview on 9/19/23 at 10:09 a.m., RN-A verified receiving 10 tablets of 5 mg oxycodone for R1 on 8/28/23. RN-A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility did not evaluate training program and re-train staff regarding allegations of verbal abuse for 1 of 1 residents (R2) reviewed for verbal abuse. Findings include: R2's significant change MDS dated [DATE], showed intact cognition, and indicated no behaviors. The MDS listed R2's active diagnoses, including stroke, pneumonia, diabetes mellitus, and depression. R2's care plan indicated communication deficit related to minimal hearing loss. The care plan directed staff to encourage R2 to continue stating thoughts even if he is having difficulty, and respond to the feeling resident is trying to express; to observe and document frustration level and wait 30 seconds before providing with word; and to use communication techniques which enhance interaction, and clarify to ensure understanding. The careplan also indicated R2 a vulnerbale adult and susceptible to abuse. The careplan directed staff to ensure R2 was in a safe environment. During interview on 9/20/23 at 8:13…

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 the resident and determine safety for self-administration of medications (SAM) for 2 of 2 residents (R16 and R28) reviewed for SAM. Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and was diagnosed with non-ST elevated myocardial infarction (type of heart attack), type 2 diabetes mellitus, hypertension (high blood pressure), coronary artery disease and was independent with most activities of daily living (ADL's). During an interview on [DATE], at 3:23 p.m., R16 stated he was able to self-administer all his medication except his nitroglycerin. R16 stated he would like to self-administer his nitroglycerin and had requested to do so back in December of 2022, after an incident where he had chest pain and waited fifty minutes before he received the nitroglycerin. R16 stated he was told he could not self-administer the nitroglycerin but was never given a reason to why…

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 up and assess a resident who requested to self-administer nitroglycerin medication for 1 of 1 resident (R16) reviewed for choices. Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and was diagnosed with non-ST elevated myocardial infarction (type of heart attack), type 2 diabetes mellitus, hypertension (high blood pressure), coronary artery disease and was independent with most activities of daily living (ADL's). During an interview on 6/12/23, at 3:23 p.m., R16 stated he would like to self-administer his nitroglycerin and had requested to do so back in December of 2022, after an incident where he had chest pain and waited fifty minutes before he received the nitroglycerin. R16 stated he was told he could not self-administer the nitroglycerin but was never given a reason to why not. R16's signed physician orders dated 12/5/22, indicated R16 could self-administer medications…

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 bathing assistance was provided for 1 of 4 resident (R10) reviewed for activities of daily living (ADL's). Findings include: R10's annual Minimum Data Set (MDS) dated [DATE], indicated R10 has mildly impaired cognition and was diagnosed with cardiomegaly (enlarged heart), obesity, hypertension (high blood pressure), chronic kidney disease, and required moderate assistance with bathing. R10's care plan updated on 5/1/23, indicated R10 required an assist of one staff with shower twice weekly and as necessary. During an observation on 6/13/23 at 12:08 p.m., R10 had a strong body odor notable from the hallway outside his room. R10's electronic health record (EHR) indicated he received a shower on 6/6/23, refused a shower on 6/9/23 and not applicable was documented for his shower scheduled on 6/13/23. During an observation and interview on 6/14/23, at 9:32 a.m., R10 had strong body odor present. R10's polo shirt had dried food stains…

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.