Maplewood Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident-centered care plans were developed, implemented, and revised to accurately reflect resident's current needs for 3 of 3 residents reviewed (R55, R102, and R109). Specifically, the facility failed to include required interventions for edema management, failed to update the care plan to remove discontinued enhanced barrier precautions, and contained conflicting information regarding the level of assistance required for eating. These deficient practices resulted in the potential for inconsistent care, unmet resident needs, and compromised resident safety and well-being.Findings include:R55R55's quarterly Minimum Data Set (MDS) dated [DATE] identified R55 had intact cognition and required assistance with activities of daily living (ADLs). R55's diagnoses included heart failure (impaired heart pumping function), hypertension (high blood pressure), hyperlipidemia (elevated blood cholesterol), schizophrenia (chronic thought disorder), pulmonary…

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 activities of daily living (ADLs) related to hygiene and grooming were provided in accordance with resident needs for 1 of 1 residents reviewed (R88) by failing to ensure the resident wore clean clothing throughout the survey period. This deficient practice resulted in the potential for compromised dignity, discomfort, and negative psychosocial impact to the resident.Findings include:R88's quarterly Minimum Data Set (MDS) dated [DATE], identified R88 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R88's diagnoses included cancer (abnormal cell growth), anemia (low red blood cells), hypertension (high blood pressure), renal failure (impaired kidney function), obstructive uropathy (blocked urine flow), diabetes mellitus (impaired blood sugar regulation), arthritis (joint inflammation), non-Alzheimer's dementia (cognitive decline not due to Alzheimer's disease), urinary retention (inability to fully…

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 activities were provided or offered in accordance with resident needs and preferences for 1 of 1 resident reviewed (R109). Specifically, the resident remained in bed for the duration of the survey without activities being offered or provided. This deficient practice resulted in the potential for social isolation, decline in psychosocial well-being, and decreased quality of life.Findings include:R109's quarterly Minimum Data Set (MDS) dated [DATE], identified R109 had intact cognition and required assistance with activities of daily living (ADLs). R109's diagnoses included hemiplegia following cerebral infarction affecting the right dominant side (paralysis or weakness on the right side due to stroke), hypertension (high blood pressure), diabetes mellitus (impaired blood glucose regulation), hyperlipidemia (elevated cholesterol or fats in the blood), malnutrition (insufficient nutrient intake), bipolar disorder (mood disorder with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure audiology appointments were available for 1 of 1 resident (R67) who requested audiology services. Findings include:R67's annual Minimum Data Set (MDS) dated [DATE], indicated R67 had adequate hearing and had no difficulty in normal conversation, social interaction, listening to the TV and did not wear a hearing aid. Further, R67 had moderate cognitive impairment, was very important to have family or a close friend involved in discussion about care and was very important to listen to music.R67's quarterly MDS dated [DATE], indicated R67 had adequate hearing and did not use a hearing aid, had moderate cognitive impairment, and had initially been admitted to the facility on [DATE].R67's Medical Diagnosis form, undated, indicated the following diagnoses: Parkinson's disease, dementia, and depression. R67's HealthDrive consent form dated 1/31/24, indicated R67 wanted to be seen for audiology.R67's HealthDrive consent form dated…

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 prescribed treatment for urinary tract infection (UTI) prevention was administered or reported as refused for 1 of 2 residents (R47) reviewed for recurring UTIs. Findings include:R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 was cognitively intact, was dependent on staff for toileting and required substantial/maximum assistance for transfers and mobility. The MDS indicated R47 was frequently incontinent of bowel and bladder, did not have any urinary device. R47 did not exhibit rejection of care behavior. R47's diagnoses included chronic kidney disease, diabetes mellitus, and urinary tract infection.R47's care plan dated 1/13/26, indicated alteration in elimination with a goal to be free from signs and symptoms of UTI.R47's October 2025, medication administration record (MAR) indicated, Estradiol Vaginal Cream 0.1 MG/GM (milligrams/gram)[Estradiol Vaginal] Apply to inner vulvar & urethral topically one time 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 observation, interview, and document review, the facility failed to ensure specific patient centered orders were in place and implemented for colostomy care for 1 of 1 resident (R81) reviewed for colostomy care. Findings include:R81's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have hallucinations or delusions, did not reject care, used a wheelchair, was dependent on staff for toileting hygiene, showering or bathing, and lower body dressing. Additionally, R81 had an colostomy and diagnoses included unspecified dementia, anxiety, depression, and malnutrition and did not have any skin conditions. R81's Physician's Orders form saved on 12/1/25 at 2:05 p.m., indicated the following orders:7/28/23, and discontinued on 8/1/23, left lower quadrant colostomy remove pouch and discard. Cleanse the peristomal skin with only tap water, pat dry. Apply [NAME] number 8664, 1 1/4 inch precut convex drainable pouch. Have the resident hold her hand over the pouch for a few minutes.…

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 respiratory care and services were provided in accordance with physician orders and professional standards of practice for 1 of 1 residents reviewed (R109). Specifically, the facility administered oxygen therapy without a physician's order. This deficient practice resulted in the potential for improper oxygen administration, respiratory compromise, and harm to the resident.Findings include:R109's quarterly Minimum Data Set (MDS) dated [DATE] identified R109 had intact cognition and required assistance with activities of daily living (ADLs). R109's diagnoses included hemiplegia following cerebral infarction affecting the right dominant side (paralysis or weakness on the right side due to stroke), hypertension (high blood pressure), diabetes mellitus (impaired blood glucose regulation), hyperlipidemia (elevated cholesterol or fats in the blood), malnutrition (insufficient nutrient intake), bipolar disorder (mood disorder with manic…

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 maintain accurately documented medical records for 3 of 3 residents (R47, R68, R83) reviewed who had inaccurate documentation. Findings Include: Findings include: R47 R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 was cognitively intact, was dependent on staff for toileting and required substantial/maximum assistance for transfers and mobility. The MDS indicated R47 was frequently incontinent of bowel and bladder, did not have any urinary device. R47 did not exhibit rejection of care behavior. R47's diagnoses included dislocation of left patella (kneecap), chronic kidney disease, diabetes mellitus, and urinary tract infection. R47's care plan dated 1/13/26, indicated alteration in elimination with a goal to be free from signs and symptoms of UTI. R47's October 2025, medication administration record (MAR) indicated, Estradiol Vaginal Cream 0.1 mg (milligram)/GM (Gram) [Estradiol Vaginal] Apply to inner vulvar & urethral…

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 appropriate infection control measures were in place for maintaining a central line with dressing changes and use of enhanced barrier precautions (EBP) with personal protective equipment (PPE) for 1 of 2 residents (R36) reviewed who had a central line indwelling device.Findings include:R36's admission Minimum Data Set (MDS) dated [DATE], indicated R36 had moderate cognitive impairment and required substantial/maximal assistance for most activities of daily living (ADL) and transfers. R36's diagnoses include spastic hemiplegia (paralysis on one side of the body) affecting the right, dominant side, osteomyelitis (infection of the bone), and history of traumatic brain injury. R36's care plan (CP) dated 10/8/25, indicated resident was on EPB related to IV (central line). The CP instructed staff to use appropriate PPE when providing high contact cares. R36's CP indicated EBP was resolved 11/3/25. R36's treatment administration record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a resident's primary medical provider was notified of changes in condition for 1 of 1 resident (R1) who exhibited increased pain and extremity swelling after a fall, which required x-ray services, along with failure to ensure a physician order was acted upon for R1 after she returned from the emergency department (ED).Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. R1's diagnoses included, but not limited to, diabetes, stroke, malnutrition, depression, bipolar disorder, chronic pain syndrome, insomnia, and vascular dementia. Additionally, R1 continued with hospice care. She was administered scheduled pain medication during the five days of the assessment period; however, no PRN medications and/or non-medication interventions for pain. R1 was unable to participate in the pain questionnaire and staff interview(s) indicated R1 lacked indicators of pain, or possible pain, during 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 document review the facility failed to ensure enhanced barrier precautions (EBP) were implemented with the use of personal protective equipment (PPE) during high-contact resident care activities for 1 of 1 residents (R39) who had a central line, 1 of 1 residents (R38) who had wound dressings changed, and 1 of 3 residents (R11) observed during personal cares. The facility also failed to ensure appropriate hand hygiene was utilized for 1 of 2 residents (R38) observed during personal cares, and failed to ensure shared resident equipment was disinfected between uses for 1 of 1 residents (R3) observed for shared equipment. Lastly, the facility failed to ensure re-usable ice packs for clinical use were stored separately from food storage in 3 of 3 kitchen refrigerators. Findings include: R39's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care or behaviors, partial/moderate assistance needed for upper body dressing and supervision for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a multi-resident shower room ceiling exhaust fan was cleaned. This had the potential to affect all residents on the third floor who used the shower room. Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition. A Monthly Deep Clean Schedule form undated, indicated the 3rd floor long-term care north and south unit spa/bathrooms were deep cleaned on day 6 of the month. A Deep Clean Calendar dated October 2024, indicated spas were scheduled to be cleaned on 10/6/24. A November 2024 Deep Clean Calendar form was not provided. A procedure, undated, Deep Clean Procedures, indicated to check the posted deep clean schedule and clean the scheduled deep clean room. Further, the procedure directed staff to wipe the top and all sides of heating units and check top vents for accumulation of dust or other debris for resident rooms and to use a high duster to clean vents in restrooms. During interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a resident's right to determine their own healthcare decisions for 1 of 1 resident (R30), and failed to ensure R30 had a right to revoke a power of attorney. Findings include: According to Minnesota Statutes 145C.06, a health care directive is effective for a health care decision when it meets the requirements of section 145C.03, subdivision 1; and the principal in the determination of the attending physician, advanced practice registered nurse, or physician assistant of the principal, lacks decision making capacity to make the health care decision; or if other conditions for effectiveness otherwise specified by the principal have been met. A health care directive is not effective for a health care decision when the principal , in the determination of the attending physician, advanced practice registered nurse, or physician assistant of the principal, recovers decision -making capacity; or if other conditions for effectiveness otherwise…

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 notify the physician of a change in condition for 1 of 1 resident (R18) who was experiencing new vision loss. Findings include: R18's 5-day Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of type II diabetes mellitus, hypertension (HTN), and congestive heart failure (CHF). It further indicated R18 had adequate vision and didn't wear corrective lenses. R18's care plan dated 4/1/24, indicated adequate vision, able to read 12 point font, and does not wear glasses with an intervention to observe for signs and symptoms of changes in visual status and to notify the medical doctor (MD) if noted. R18's visit summary note from his last eye exam dated 7/30/24, indicated to schedule an appointment with a local retinal specialist/ophthalmology as soon as possible (ASAP) for evaluation and treatment. R18's physician's orders dated 11/6/24, indicated R18 had an appointment on 11/21/24 at 9:00 a.m. to see the retina…

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 invited to care conferences for 1 of 1 resident (R30) reviewed for care planning. Findings include: R30's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have evidence of an acute change in mental status, did not have inattention, disorganized thinking, or an altered level of consciousness, did not have physical, verbal, or other behaviors, was not important at all to have a family or close friend involved in discussions about care and had the following diagnoses: anemia, hypertension (high blood pressure), dementia, anxiety, depression, borderline personality disorder, and personal history of other mental and behavioral disorders. R30's Profile form in the electronic medical record (EMR) indicated R30's FM-A was her financial power of attorney (POA) and next to the heading, Power of attorney-care indicated, Do Not Use. R30's medical record was reviewed and lacked information R30 had a guardian.…

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 swallow study referral discharge needs were identified in the post-discharge plan for 1 of 1 resident (R54) reviewed for discharge. Findings include: R54's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of type one diabetes mellitus (DM1), dysphagia (difficulty swallowing), heart failure, hypertension, kidney disease and depression. R54 was on a therapeutic diet and active discharge planning was place. R54's Care Area Assessment (CAA) dated 9/25/24, identified functional abilities (self-care and mobility) was triggered. R54 was admitted with poorly controlled DM1, end stage renal disease on dialysis, dysphagia, weakness, and muscle spasms. Physical, occupational and speech therapy were to evaluate. R54 had a history of noncompliance with medications and was at risk for decline related to medication noncompliance and diabetic complications. R54's care plan dated 9/13/24, identified the goal was to return 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 During observation, interview, and record review the facility failed to ensure that residents received proper treatment to maintain vision for 1 of 1 resident (R18) reviewed for vision services. Findings include: R18's 5-day Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of type II diabetes mellitus, hypertension (HTN), and congestive heart failure (CHF). It further indicated R18 had adequate vision and didn't wear corrective lenses. R18's care plan dated 4/1/24, indicated adequate vision, able to read 12 point font, and does not wear glasses with an intervention to observe for signs and symptoms of changes in visual status and to notify the medical doctor (MD) if noted. R18's visit summary note from his last eye exam dated 7/30/24, indicated to schedule an appointment with a local retinal specialist/ophthalmology as soon as possible (ASAP) for evaluation and treatment. R18's physician's orders dated 11/6/24, indicated R18 had an appointment on 11/21/24 at 9:00 a.m. to see 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 document review, the facility failed to ensure resident was adequately assessed for safe smoking for 1 of 1 resident (R15) reviewed for smoking. In addition, the facility failed to ensure an identified safety hazard was acted upon for 1 of 2 residents (R50) reviewed for resident to resident abuse. Findings include: R15's PPS (prospective payment system) Part A-Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact, was independent or required supervision with most activities of daily living (ADLs), used intermittent oxygen therapy, and required a wheelchair for mobility. R15's diagnoses included hereditary motor and sensory neuropathy (nerve condition causing tingling, swelling or muscle weakness), and chronic respiratory failure. R15's care plan last updated prior to survey start on [DATE], indicated R15 smoked independently, agreed to wear a smoking apron, and required smoking material to be stored in the treatment cart. The care plan further indicated 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 observation, interview, and document review, the facility failed to ensure supplemental oxygen was properly maintained and accurately documented per professional standards for 1 of 1 resident (R20). Findings include: R20's significant change Minimum Data Set (MDS) dated [DATE], indicated R20 had intact cognition and the following diagnoses: pulmonary embolism (a blockage in the lung artery) without acute cor pulmonale (enlarged right ventricle due to a lung condition), enterocolitis due to clostridium difficile, and unspecified dyspnea. R20's Physician Orders form indicated the following orders: • 8/26/24, monitor for skin breakdown around the nose and behind the ears caused by oxygen tubing every shift. • 8/27/24, and discontinued on 10/29/24, staff to follow enteric contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) due to C. Difficile (a bacteria that causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 2 of 5 residents (R5 and R20) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccination recommendations. Findings include: R5's Resident Information form dated 11/7/24, identified she was admitted on [DATE], and was currently [AGE] years old with diagnoses which increased the risk of pneumococcal disease including chronic obstructive pulmonary disease, heart failure and history of acute respiratory failure. R5's undated Immunizations form identified the PCV-13 and PPSV23 were given on 2/23/15. R5's vaccine consent form dated 9/7/24, identified she consented to receive the pneumococcal vaccines per primary care provider order and CDC guidelines. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 9/12/24, identified based on R5's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an allegation of resident sexual abuse to the State Agency (SA) immediately, but not later than two hours after the allegation is made, for 1 of 1 resident (R1) reviewed who reported an allegation of sexual abuse in the facility. Findings include: R1's Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia, traumatic brain injury, seizure disorder, depression, post-traumatic stress disorder, and encounter for palliative care. R1 had moderate cognitive impairment and was dependent on staff for all hygiene cares, mobility, and transfers. R1's care plan focus dated 5/24/24, identified R1 as a vulnerable adult. It included an intervention dated 5/24/24, the local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. Nursing Home Incident Report #357954 submitted 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 monitor edema and comprehensively assess non-pressure related wounds for 1 of 1 resident (R2) reviewed. Findings Include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted on [DATE] with diagnoses including malignant neoplasm of brain (brain cancer), hypertension, and chronic ischemic heart disease (weakening of the heart caused by reduced blood flow) and was receiving hospice care. R2's active physician order dated 2/19/24, directed nurses to chart R2's condition in nurse's notes every shift for edema (fluid retention in body tissues that can result in swelling and/or weight gain) checks noting edema as present or not present and lung checks noting lungs as clear or not clear. R2's treatment administration records (TAR) were reviewed in conjunction with progress notes and skin evaluations, it was not evident edema was consistently comprehensively evaluated. Although the TAR's which identified the physician…

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 provide nursing cares in a sufficient amount of time for ten of ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10) reviewed for call light times. R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 depend on staff for assistance in their activities of daily living and there are delays in cares during to these call light times. Findings include: R1's admission record printed on 2/1/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder bipolar type and obesity. Additional pertinent diagnoses include morbid obesity, urge incontinence, limitation of activities due to disability, dependence on wheelchair, and muscle weakness. R1's care plan completed on 7/11/23 indicated R1 needs an assistance of one staff with dressing, grooming, and toileting, extensive assistance with bathing, and wears disposable briefs. R1's care plan indicated the prompt response by staff to all requests for assistance…

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 protect the dignity of three of ten residents (R3, R6, R8) reviewed when residents were left soiled in their incontinent brief for extended periods of time. Findings include: R3's admission record printed on 2/1/24 states R3 was admitted to the facility on [DATE] with a primary diagnosis of heart failure. An additional pertinent diagnosis includes the absence of left foot. R3's Patient Activities of Daily Living (ADL) Recommendations assessment dated [DATE] indicated R3 was dependent upon staff for lower body dressing and toileting. The assessment does not indicate how many staff R3 is dependent upon for lower body dressing and toileting. The assessment indicated R3 was dependent upon two staff members for bed mobility and transfers using a EZ Lift (Hoyer). R3's Bowel and Bladder Data Collection assessment dated [DATE] indicated R3 is always incontinent of his bowels. The assessment indicated his bowel incontinence is managed using disposable briefs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a baseline care plan was reviewed and provided timely to ensure knowledge of care and promote person-centered care planning for 1 of 2 residents (R24) reviewed for care planning. Findings include: R24's face sheet undated, indicated R24 admitted to the facility 9/11/23, was readmitted to the hospital on [DATE], and readmitted to the facility on [DATE] R24's admission cognition assessment dated [DATE], indicated R24 was cognitively intact. R24's diagnoses list dated 9/11/23, indicated R24's diagnoses included spinal stenosis cervical region, diabetes mellitus, occlusion and stenosis of left carotid artery, and cerebral infarction (disrupted blood flow to the brain) R24's baseline care plan initiated 9/12/23, included pain, psychotropic medications, respiratory diagnosis, and skin with no interventions listed. During interview on 10/26/23 at 12:20 p.m., R24's significant other (SO) indicated he had not received any information regarding R24'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 revise the care plan for 1 of 1 resident (R54) reviewed for ongoing medication refusals. Findings include: R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 had cognitive impairment and rejection of care which occurred one to three days in a seven day period. R54's face sheet printed 10/23/23, indicated diagnosis of major depressive disorder recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest) generalized anxiety disorder (GAD; the feeling of being extremely worried or nervous more frequently about things, even when there is little or no reason to worry about them), dissociative and conversion disorder (mental health conditions that can occur together. Dissociative disorders cause a person to become disconnected from important aspects of their lives. Conversion disorder causes physical symptoms that mimic neurological conditions), and personal history of transient ischemic attack ( a stroke…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to monitor skin conditions for 1 of 1 resident (R238) who had facial bruising upon admission. The facility also failed to ensure physician's orders were accurately transcribed for 1 of 1 resident (R13)reviewed who required follow-up care after skin excisions. Findings include: R238's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of displaced fracture of the second cervical vertebra, osteoporosis with current pathological fracture, chronic pain syndrome, and syncope (fainting) and collapse. It further indicated R238 required moderate assistance with activities of daily living (ADL), dependent on staff for transfers and mobility and had a fall with fracture prior to admission. R238's admission/readmission (day 1) assessment dated [DATE], indicated R238 had facial bruising under her right eye. R238's nursing weekly skin checks dated 10/15/23 and 10/22/23 lacked documentation of the bruise under 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 interventions were in place for 1 of 2 residents (R12) at risk for pressure ulcers. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was cognitively impaired, required two person total assistance for most activities of daily living (ADLs) and was at risk for developing pressure ulcers, and had two stage II ulcers (partial thickness lost of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. may also present as an intact or open/ruptured serum filled blister) and one stage III pressure ulcer (full thickness tissue loss. subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). R12's diagnosis included end stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), dementia, obesity, diabetes mellitus with neuropathy, and anemia. R12's care plan printed 10/26/23, indicated R12 had alteration in skin integrity related to mobility…

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 medical record reflected accurate care and monitoring of the dialysis access site for 1 of 1 residents (R23) reviewed for dialysis. Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care and diagnoses of kidney failure and dialysis dependency. R23 required substantial/maximal assistance with upper body dressing. R23's Care Plan dated 4/21/22, identified a dialysis shunt location (central line) in the right upper chest. Interventions included no blood draws from central line, and in emergency situations if shunt started to bleed, apply ice and pressure, if bleeding does not cease after 15 minutes, call 911, doctor, dialysis and family. The care plan lacked interventions related to a dialysis fistula such as removing a pressure dressing after dialysis session, assessment of bruit and thrill (sounds and vibrations that indicated a fistula worked properly), and to ensure no blood…

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 assess for and identify potential triggers for 1 of 1 resident (R28) who had a history of trauma. Findings include: R28's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care and diagnoses of depression, bipolar disease and post-traumatic stress disorder (PTSD). R28 had several days in the lookback period where he felt little interest or pleasure in doing things or felt down, depressed, or hopeless. R28's Mood/Trauma care plan dated 7/25/18, identified a diagnosis of PTSD. Interventions included to call 911 in an urgent situation, complete a suicide self-harm interview as needed, remove items resident threatens to kill himself with, implement Threats to Self Harm policy and 1:1 checks, refer to psychologist as needed and encourage to express feelings and utilize family. The care plan lacked identification of triggers which had the potential to re-traumatize. R28's Social Services Resident History, Demographics…

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 antibiotic medications had appropriate monitoring, diagnosis, and indication for use for 1 of 1 resident (R15) reviewed for unnecessary medications. Findings include: R15's quarterly minimum data set (MDS) dated [DATE], indicates a brief interview for mental status (BIMS) score of 15, and R15 had an indwelling urinary catheter. R15's hospital progress plan note dated 8/9/23, had the order to continue Bacitracin three times daily to reduce catheter irritation. R15's provider orders (after visit summary) dated 8/11/23, included the medications Bacitracin (topical antibiotic ointment) and cefpodoxime (oral antibiotic). R15's order summary report printed 10/26/23, included provider orders since 8/1/23, which did not include an order for Bacitracin. However, the follow-up visit dated 9/5/23, included Bacitracin for catheter care. R15's treatment administration record (TAR) for October 2023, has Bacitracin for catheter 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 implement protocols to ensure appropriate antibiotic treatment was in place for 1 of 1 resident (R15) with an active infection. Furthermore, the facility failed to ensure monitoring and documentation of prophylactic antibiotic use for 1 of 1 resident (R15) reviewed for antibiotic stewardship. R15's quarterly minimum data set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS) score of 15, and R15 has an indwelling urinary catheter. R15's provider orders (after visit summary) dated 8/11/23, included the medications Bacitracin and cefpodoxime (oral antibiotic), and follow-up visit dated 9/5/23, included Bactrim and Bacitracin. R15's medication administration record (MAR) for October 2023, revealed administration of Bactrim twice daily for 10 days, Diflucan (an antifungal), and continuation of Bacitracin three times daily with catheter care. R15's care plan printed 10/26/23, indicated a self-administration of medication plan started…

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.