Providence Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed for 1 of 1 residents (R155) reviewed for activities of daily (ADLs) and who were dependent on staff for their care.Findings include:R155's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R155 had moderately impaired cognition, no hallucinations, delusions, behaviors or rejection of care. R155 was dependent on staff assistance for dressing, oral hygiene, toileting, mobility, and showering. Furthermore, R155 received hospice services.R155's diagnosis report, printed 5/14/26, included the following relevant diagnoses: vascular dementia without behavioral disturbances (cognitive decline from restrictive brain blood flow without exhibited behaviors such as aggrieve, anxious, psychoses or mood-altering symptoms), glaucoma-severe stage (advanced irreversible optic nerve damage where person experiences severe tunnel visions, compromised daily function 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 document review, the facility failed to ensure insulin was administered as ordered for 1 of 2 residents (R2) reviewed for insulin administration and wound care was provided as ordered for 1 of 1 resident (R60) reviewed for pressure ulcers.Findings include: R2 - not following provider orders R2's admission Minimum Data Set (MDS) assessment dated [DATE], identified R2 had intact cognition without hallucinations or delusions present with no behaviors, or rejection of care present. Diagnoses included diabetes. Furthermore, Section N: Medication identified R2 received insulin injections 4 days out of 7 days. During an interview on 5/11/26 at 2:34 p.m., R2 stated she received insulin injections for her diabetes. R2's care plan, printed 5/13/26, included the following: -has diabetes mellitus with a goal of will be free from any s/sx [signs/symptoms] of hypoglycemia through the review date with the following interventions: Dietary consult for nutritional regimen and ongoing…

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 orders included resident-specific settings for the use and management of non-invasive ventilation machines for 2 of 2 residents (R15, R23) reviewed for the use of CPAP/BiPAP machines. In addition, the facility failed to ensure oxygen-related orders were reinstated after hospitalizations and readmission to the facility for 1 of 1 resident (R51) who used oxygen. Findings include: R15 R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R15's short term or long-term memory were both marked as memory ok after staff assessment of mental status was completed. In Section O- Special Treatment, Procedures and Programs, in section G1 Non-invasive mechanical ventilator was marked with a check mark to indicate R15 uses a non-invasive mechanical ventilator. During an observation on 5/11/26 at 12:47 p.m., a non-invasive ventilation machine (CPAP/BiPAP machine) on the bedside table. The mask for the machine was observed laying on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary behavioral health services, trauma-informed care planning, and coordinated mental health support for 1 of 1 resident (R130) reviewed for behavioral health services. The facility failed to implement interventions to address ongoing sanitation and environmental concerns in the resident's room, failed to develop and implement interventions to address R130's identified trauma triggers and feelings related to loss of control over her surroundings, and failed to revise or implement new behavioral health interventions after 10/24/25 despite continued concerns which had the potential to result in unmet psychosocial needs and unsafe living conditions. Findings include:R130's quarterly Minimum Data Set (MDS), dated [DATE], identified R130 was admitted to the facility on [DATE], was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, and was independent with most activities of daily living.R130'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 ensure medically related social services were provided for 1 of 1 residents (R61) observed who wore mismatched shoes which caused discomfort, despite staff knowledge of the lack of matching shoes.Findings include:R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 had intact cognition and was diagnosed with diabetes, depression, and an amputation. The MDS indicated R61 had no hallucinations, delusions, behavioral symptoms directed towards others, or rejection of care behaviors.R61's care plan dated 5/26/26 indicated R61 had a self-care performance deficit related to a right below-the-knee amputation. The care plan indicated R61 preferred to choose his own clothing and what to wear. The care plan indicated he required moderate assistance with tub/shower transfers, showering/bathing, and lower body dressing.R61's medical record was reviewed, and did not indicate that prior to survey entrance, staff had attempted to assist…

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 consultant pharmacist (CP) recommendations were acted upon timely for 1 of 5 residents (R129) reviewed for unnecessary medications. In addition, the facility failed to develop and/or implement a procedure outlining follow-up time frame expectations in the drug regimen review process for 1 of 5 residents (R118) reviewed for unnecessary medications. Findings include: R129 R129's admission Minimum Data Set (MDS) dated [DATE], indicated R129 had intact cognition and received high risk medications to include antianxiety and anticoagulant. R129's diagnoses include panic disorder, generalized anxiety disorder, atrial fibrillation, and peptic ulcer. R129's diagnoses lack evidence of diabetes mellitus (DM). R129's provider orders indicated the following: -Dated 3/30/26, Meloxicam Oral Tablet.Give 7.5 mg by mouth two times a day for INFLAMMATORY. R129's provider order lacked evidence of additional instructions to give with food or milk. -Dated 3/30/26,…

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

Based on observation, and interview, the facility failed to ensure food was served at palatable temperatures for 1 of 1 residents (R88) who were observed and served cold food.Findings include: During the lunch dining service at the transitional care unit on 5/12/26 at 12:03 p.m., nursing assistant (NA)-A rolled a meal tray to R88's room to deliver lunch of honey mustard chicken, potato fingerlings, and a mixture of cooked vegetables. Dietary aide (DA)-A temped the food prior to NA-A delivering the tray into R88's room. Results of the temperatures were as follows:Honey Mustard Chicken was 117 degrees Fahrenheit (F)Potato fingerlings were 118 degrees F, andMixed vegetables were 100 degrees F.DA-A stated the chicken was supposed to be 145 degrees and above when we are serving. DA-A stated, I would want the food to be warmer than this when I eat it.During interview with DA-A and cook (C)-A on 5/12/26 at 12:06 p.m., both stated the food sits on the trays too long [before residents are served].During interview with R88 on 5/12/26 at 12:46 p.m., R88 stated, the chicken was cooked but…

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 identify the indication for the administration of opioid medications and failed to ensure non-pharmacological interventions were attempted/offered and documented prior to the administration of as needed (PRN) opioid medications for 2 of 3 residents (R1, R2) reviewed for pain. Findings include:R1's admission minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses including end stage renal disease (ESRD) and pressure ulcer of heel. R1's pain assessment dated [DATE] indicated R1 had pain that frequently interfered with therapy and day-to-day activities. R1 received scheduled and as needed (PRN) medications for pain. R1 had not received non-medication interventions for pain.R1's care plan dated 12/23/25 had a focus of actual chronic neuropathic pain with need for medication management related to neuropathy. Interventions included but not limited to: offer non-pharmacological interventions for pain relief such as rest or repositioning…

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 include in the care plan interventions for safe eating and swallowing for 1 of 2 residents (R1) reviewed for quality of care and treatment. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of unspecified tremor (involuntary movement), absence of other parts of the digestive tract (removal or absence of part of the digestive tract which could be stomach, intestines or other components), and dysphagia oropharyngeal phase (swallowing disorder occurs in the mouth and throat affecting the ability to swallow both liquids and solids). R1 had cognition impairment. R1 required set up assistance with meals. R1 did not have difficulty with coughing or choking during meals or when swallowing medications. R1's care plan dated 1/16/25, identified a self-care performance deficit with an intervention labeled eating: set up. R1's physician order dated 1/16/25, identified regular textured diet with thin liquids. R1's 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 observation, interview, and document review, the facility failed to develop and implement an individualized behavioral health care plan utilizing recommendations from professional psychological services to support sobriety efforts for 2 of 2 residents (R2 and R3) reviewed for behavioral health needs. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, cardiac-respiratory issues, COPD, depression, and dementia. The MDS indicated no mood or behavior issues, R2 was independent with mobility, activities of daily living (ADL)'s, and had troubles with breathing with exertions. R2's Care Plan revised on 4/16/25, indicated R2 had cognitive loss/dementia or alteration in thought process's ability, judgement and decision making. The Care Plan further indicated R2 had major depression and received services in-house from the psycho-geriatric team, and staff were to observe behavior and attempt to determine pattern, frequency, intensity and triggers,…

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 routine personal hygiene cares (i.e., nail care, showering, facial hair removal, personal cares, dressing assistance) were offered and/or completed for 4 of 6 residents (R62, R37, R112, R64) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares. Findings include: R62 R62's annual MDS, dated [DATE], identified R62 had intact cognition and had multiple medical conditions including progressive neurological disease, multiple sclerosis (MS), and malnutrition. Further, the MDS identified R62 demonstrated no rejection of care behaviors and required substantial/maximal assistance with personal hygiene cares. R62's most recent Body Audit 11-15-V8, dated 2/21/25, identified R62 had a bed bath completed and listed a section which read, Nails. The section had questions to be answered by staff about what, if any, cares were completed. This identified R62's fingernails were clean and trimmed, and R62…

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 developed skin conditions were identified, assessed and acted upon in a timely manner to promote healing and reduce the risk of complication (i.e., infection, worsening) for 2 of 2 residents (R103, R158) reviewed who had skin impairments. Findings include: R103 R103's admission Minimum Data Set (MDS), dated [DATE], identified R103 had intact cognition, demonstrated no delusional thinking, and was dependent on staff for dressing and bed mobility. Further, the MDS identified R103 had several medical complications including cancer and diabetes mellitus, but had no current skin impairments (i.e., ulcers, surgical wounds, lesions on the foot). R103's care plan, printed 2/25/25, outlined all of R103's identified potential or actual problems along with corresponding interventions. The care plan outlined R103 had a self-care deficit and needed assistance with lower body dressing, bathing, and bed mobility; R103 had a history of false…

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 implement planned fall interventions for 1 of 2 residents (R125) reviewed for falls. Findings include: R125's quarterly Minimum Data Set (MDS) dated [DATE], identified R125 had moderately impaired cognition and had diagnoses which included cancer, hip fracture, other fracture, personal history of traumatic brain injury, and history of falling. The MDS indicated R125 required substantial and/or maximal assistance with toileting hygiene and transfers. The MDS indicated R125 had two or more falls with no injury since prior assessment. R125's care plan printed 2/24/25, indicated R125 had limited physical mobility with fall risk related to history of falls, and falls were anticipated related to impulsivity, cognition, multiple attempts to self-transfer, and incontinence. Interventions included auto-locking brakes to wheelchair, gripper socks or shoes on at all times, keep wheelchair at bedside when in bed, and identified R125's mobility 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 document review, the facility failed to ensure assessed and ordered nutritional supplement interventions were followed for 1 of 1 resident (R18) reviewed for weight loss. Findings include: R18's annual Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and required supervision or touching assistance with eating. R18 had diagnoses which included dementia, peripheral vascular disease, chronic viral hepatitis C, chronic obstructive pulmonary disease, dysphagia, constipation, hemiplegia (partial or total loss of voluntary movement on one side of the body) or hemiparesis (weakness on one side of the body), multiple sclerosis (chronic, autoimmune disease which affects the brain and spinal cord), and schizophrenia. The MDS identified R18 weighed 146 pounds, had sustained no substantial weight loss or weight gain in the previous six months, and had a mechanically altered diet. R18's comprehensive Nutritional assessment dated [DATE], indicated R18'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.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were consistently implemented in accordance with Centers for Disease Control (CDC) recommendations to reduce the risk of infection for 2 of 3 residents (R38, R25); and failed to ensure appropriate hand hygiene was completed during provision of personal care for 1 of 4 residents (R25) whose cares were observed. Findings include: EBP: A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents 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 interviews and record review, the facility failed to ensure staff had not taken unauthorized pictures without consent for 1 of 4 residents (R4) reviewed for abuse. This had the potential for mental abuse using a reasonable person concept. Findings include: R4's quarterly Minimal Data Set (MDS) dated [DATE], indicated R4's diagnoses included paranoid schizophrenia, schizoaffective disorder bipolar type, and R4 had moderately impaired cognition. R4's Vulnerable Adult Evaluation dated 6/26/24, identified R4 had physical limitations which made him susceptible to abuse due to R4 required assistance with cares and activities of daily living (ADLs). Further, R4 was identified to have cognitive deficits which made R4 susceptible to abuse due to changes in cognition related to diagnoses of paranoid schizophrenia and unspecified symptoms and signs involving cognitive functions and awareness. R4's care plan dated 6/21/24, indicated R4 had a diagnosis of schizoaffective disorder bipolar type with paranoia and R4…

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 thoroughly investigate an allegation of staff to resident abuse for 2 of 4 residents (R1 and R4) reviewed involving 1 of 1 contracted staff (certified occupational therapy assistant (COTA)-A)). Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included anxiety disorder, major depressive disorder, paranoid personality disorder and R1 was cognitively intact. R4's quarterly MDS dated [DATE], indicated R4's diagnoses included paranoid schizophrenia, schizoaffective disorder bipolar type, and R4 had moderately impaired cognition. Review of facility report to the State Agency dated 9/24/24, indicated R1 who was no longer a resident at the facility, reported consensual sexual relations and a consensual relationship with COTA-A. On 10/1/24 at 11:20 a.m., executive director (ED) stated as part of the investigation for R1's allegation, two therapy staff were interviewed; however no facility floor staff were…

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 routine bathing, nail care and/or shaving assistance was offered or provided for 4 of 5 residents (R20, R35, R52, and R102) reviewed for activities of daily living, who were dependent of staff for assistance with bathing and/or grooming. Findings include: R35 R35's annual Minimum Data Set, dated [DATE], indicated R35 had moderate cognitive impairment and required partial to moderate assistance with bathing. R35's care plan, dated 5/1/20, indicated R35 required assistance of 1 staff with a tub bath or shower per resident's preference twice a week. R35's body audits, completed on bath days, were reviewed for the months of February and March 2024 and indicated R35 received four showers in the past two months despite being care planned for two showers a week. Showers were documented on 2/14/24, 2/28/24, 3/6/24 and 3/27/24 with a refusal documented on 3/13/24. R35's Bathing task indicated no documented bathing in the past 30 days.…

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 routine dental needs were evaluated and, if needed, acted upon or addressed timely to promote oral hygiene for 4 of 5 residents (R26, R68, R92 and R102) reviewed for dental care. Findings include: R92's quarterly Minimum Data Set (MDS), dated [DATE], identified R92 had severe cognitive impairment but demonstrated no delusional thinking behaviors. R92's previous significant change in status (SCSA) MDS, dated [DATE], identified R92 had no broken, ill-fitting dentures or obvious/likely cavities for the review period marked with, Z. None of the above were present. Further, R92's Clinical Census, printed 4/3/24, identified R92's current payer source, Medical Assistance - MN, with an effective date, 4/11/2023. On 4/1/24 at 3:37 p.m., R92 was observed seated in a standard wheelchair on the unit with her family member (FM)-C present and seated adjacent. R92 was interviewed, and expressed she used an upper partial denture but it had a few…

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 or provide the pneumococcal vaccine to 2 of 5 residents (R20 and R76) reviewed for immunizations. The facility further failed to offer or provide shared clinical decision making on the pneumococcal vaccine for 2 of 5 residents (R35 and R46) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R20's quarterly Minimum Data Set (MDS), dated [DATE],n indicated R20 was [AGE] years old, cognitively…

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 resident and/or resident representative participated in care conferences for the care planning process and development of care plan interventions for 1 of 1 residents (R82) reviewed for participation of care planning. Findings include: R82's significant change Minimum Data Set (MDS) dated [DATE], identified R82 admitted to facility on 7/18/22, had intact cognition, with diagnoses of anxiety, depression, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs abbreviated COPD), amputation of left leg above the knee, and right hip replacement. In addition, the MDS indicated R82 participated in the assessment with goal setting. During interview with R82 on 4/1/24 at 3:33 p.m., R82 stated, I haven't been a part of them (care conferences) and denied being invited or made aware of care conferences. I should know what is going on with my stay here. R82's Hospital discharge (DC)…

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 accommodate resident needs by ensuring the call light was accessible for 3 of 3 residents (R96, R114 and R10) reviewed for call lights. Findings include: R96 R96's quarterly Minimum Data Set (MDS) dated [DATE], identified R96 had intact cognition and diagnoses of schizophrenia (mental disorder in which people interpret reality abnormally), polyneuropathy (malfunction of many peripheral nerves throughout the body), lymphedema (swelling of caused by a blockage in the lymphatic system with a feeling of heaviness or tightness and loss of range of motion), morbid obesity, chronic pain and arthritis. R96 required substantial to maximal assistance with toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, sit to lying transfer and, lying to sitting transfer on the side of bed. R96's care plan (CP) dated 6/17/23, instructed nursing staff to, Orientated to call light/room During observation on 4/1/24 at 2:03 p.m.,…

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 Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning, assessment and potential interventions needed for 2 of 2 residents (R26, R68) reviewed for MDS accuracy. Findings include: BEHAVIORAL SYMPTOMS: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had a severe cognitive impairment, could wheel at least 150 feet independently once assisted into the wheelchair, and displayed no wandering behaviors. R26's MDS Reference Period Documentation note dated 3/2/24 at 5:38 p.m., indicated R26 had a behavior of wandering. R26's MDS Reference Period Documentation note dated 3/3/24 at 12:41 p.m., indicated R26 had a behavior of wandering. R26's MDS Reference Period Documentation note dated 3/3/24 at 5:50 p.m., indicated R26 had a behavior of wandering. R26's MDS Reference Period Documentation note dated 3/7/24 at 6:25 p.m., indicated R26 had a behavior 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 and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R7) reviewed for lymphedema (localized swelling caused by compromised lymphatic system) care. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], indicated R7 had impaired cognition and required maximum assistance for dressing lower part of body, footwear, toileting, bathing, transfers, and maximum assistance for dressing upper part of body. MDS indicated no behaviors present, and no rejection of care exhibited. R7's diagnoses included lymphedema, fracture of left tibia (left lower leg bone), heart failure, hypertension (high blood pressure), diabetes mellitus, hyperlipidemia (high cholesterol), dementia, presence of cardiac pacemaker, and atrioventricular block (heart rhythm disorder that caused the heart to beat more slowly than it should). Section 0 Special Treatment and Programs indicated R7 was receiving…

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 reassess and, if needed, develop interventions to ensure a developed skin condition was resolved after initial treatment was completed for 1 of 1 resident (R71) observed to have a non-pressure skin impairment on their feet. In addition, the facility failed to identify and, if needed, ensure consistently elevated blood glucose levels were assessed or acted upon to reduce the risk of complication for 1 of 2 residents (R26) reviewed for diabetes management. Findings include: SKIN NOT ASSESSED: R71's quarterly Minimum Data Set (MDS), dated [DATE], identified R71 had intact cognition, had diabetes mellitus, and had no current foot problems (i.e., infection, ulcers) or other skin-related problems (i.e., lesions, burns, tears) present during the review period. On 4/1/24 at 2:10 p.m., R71 was observed lying in bed while in her room. R71 was questioned on what, if any, skin issues she had present and responded, Just my feet. R71…

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 range of motion (ROM) restorative program was completed for 1 of 1 resident (R46) who was on a ROM program to prevent contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff that prevents normal movement of a joint or other body part.) Additionally, the facility failed to ensure a recommended splint application was completed and reassessed as needed to treat current contractures and prevent worsening contractures for 2 of 2 residents (R19 and R68) reviewed who had contractures of the hands. Findings include: R46's quarterly Minimum Data Set, dated [DATE], indicated R46 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs). The MDS further indicated R46 had limited range of motion (ROM) to her upper extremities. R46's Medical Diagnosis list, printed 4/4/24, indicated R46 had several 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment) for 1 of 1 resident (R80) reviewed for dialysis care. Findings include: R80's quarterly Minimum Data Set (MDS), dated [DATE], identified R80 had moderate cognitive impairment along with several medical conditions including anemia, high blood pressure, and renal insufficiency and/or renal failure. In addition, the MDS outlined R80 received dialysis care while a resident at the care center. On 4/1/24 at 5:58 p.m., R80 was interviewed and verified she was on dialysis. R80 explained she went to an offsite clinic for the treatment multiple times per week but was unsure where her dialysis access was located when asked (i.e., graft, port). R80 denied issues with bleeding or her dialysis care, in general, but was unsure what,…

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 act upon the consultant pharmacist's recommendation for 1 of 5 residents (R73) reviewed for unnecessary medications. Findings include: R73's quarterly Minimum Data Set (MDS) dated [DATE], identified R73 had intact cognition with diagnoses of renal insufficiency(inadequate kidney function), coronary artery disease, anemia, hyponatremia (low blood sodium levels), hyperkalemia (high blood potassium levels), depression, psychosis (severe mental condition of the mind resulting in difficulties determining what is real and what is not real), rectal abscess and a multi-drug resistant infection. In addition, it documented R73 had a colostomy (opening in the large intestine to channel stool from the body) and R73 received antipsychotic medication on a routine basis. R73's physician orders (PO) dated 3/15/24, documented R73 had a provider order for Prochlorperazine Maleate Oral Tablet (used to treat nausea, migraines, schizophrenia, psychosis and anxiety) 5…

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 (orthostatic blood pressure monitoring) was completed, in accordance with standards of care, related to antipsychotic medication use for 1 of 5 residents (R76) who had frequent falls and was 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) from antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension [which can] lead to dizziness, syncope, and falls. It should be evaluated by both history and routine measurement. R76's quarterly Minimum Data Set (MDS), dated [DATE], indicated R76 had severe cognitive impairment and required a wheelchair for locomotion around the facility. The MDS further indicated R76 had the following medical diagnoses; legal blindness and…

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

Based on observation, interview and document review, the facility failed to ensure resident room walls were maintained in a clean, sanitary manner for 1 of 1 residents (R52) whose walls were soiled and in a state of disrepair. In addition, the facility failed to ensure 1 of 2 commerical ovens used in the main production kitchen was kept in the clean, sanitary manner to reduce the risk of particle cross-contamination. This had potential to affect all 138 residents, visitors, or staff who could consume food made using the device. Findings include: RESIDENT ROOM: On 4/01/24, at 1:30 p.m., R52 was lying in bed in room and covered with a blanket in bed. R52's bed was positioned parallel with the wall. The wall was noted to have bubbling paint, torn in areas, multiple dark-brown colored smears along with other various colors of streaks on the wall. There were places on the wall, by the grab bars, where the sheet rock was exposed, and the area was larger than a fist. R52 was questioned about his walls at this time; however, R52 was unable to answer how the walls became scraped or how long…

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 personal protective equipment (PPE) was available and worn by staff according to the Center for Disease Control and Prevention (CDC) and Minnesota Department of Health (MDH) guidelines for a facility in outbreak status for 7 residents (R2, R5, R6, R7, R8, R9 and R10). This had the potential to affect all 141 residents in the building. In addition, the facility failed to correctly identify 1 of 3 residents (R4) who required isolation precautions, failed to remove precautions for 1 of 3 residents (R2) reviewed for isolation precautions. Findings include: Centers for Medicare and Medicaid (CMS) QSO-20-38-NH memo revised 9/23/22, directed, An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff. Minnesota Department of Health (MDH) COVID-19 Source Control (Masking), PPE, and Testing Grid dated 11/2/22, directed when a facility was in outbreak status, Everyone should use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure two of two residents (R1 and R2) reviewed remained free of physical and verbal abuse when the facility did not assess and care plan interventions between R1 and R2 with a history of threating behavior towards each other resulting in verbal and a physical altercation. Findings Include: On 10/30/23 at 9:07 a.m., the video footage from 10/16/23 at 4:02 p.m. was reviewed with the director of nursing (DON) and the assistant executive director. In the video, trained medication aide (TMA)-A was seen propelling R2 down the hallway and looking over her shoulder. R1 appeared around the corner propelling in his wheelchair. R1 and R2 appear to yell at each other, R2 activated the wheel locks on his wheelchair and TMA-A can no longer keep R1 and R2 separated. TMA-A remains between R1 and R2 as R1 wheeled himself closer. R1 and R2 were seen yelling and pointing at each other as TMA-A kept them separated with her body. TMA-A attempted to move…

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 abuse to the state agency, not later than two hours after an allegation is made for two of two residents (R1 and R2) reviewed for abuse. Findings include: R1's minimum data set (MDS) quarterly assessment dated [DATE] indicated R1's diagnoses included other spondylosis with myelopathy, hypertension, unspecified personality disorder, anxiety, depression, psychotic disorder, and myoclonus. R1 was independent in all functional activities of daily living and was wheelchair dependent. R1's Brief Interview for Mental Status (BIMS) was 14 out of 15, which indicated he was cognitively intact. R1's incident report dated 10/12/23 at 7:00 p.m., indicated R1 and R2 made inappropriate and explicit comments to each other and continued to become more aggressive. The incident report indicated R1 and R2 had to be physically separated by staff and the police were contacted. A nursing note dated 9/12/23 indicated another resident had attempted 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 interview and document review, the facility failed to complete investigations and thoroughly investigate into two incidents of verbal and physical abuse for two of two residents (R1, R2) reviewed for abuse. Findings include: R1's minimum data set (MDS) quarterly assessment dated [DATE] indicated R1's diagnoses included other spondylosis with myelopathy, hypertension, unspecified personality disorder, anxiety, depression, psychotic disorder, and myoclonus. R1 was independent in all functional activities of daily living and was wheelchair dependent. R1's brief interview for mental status (BIMS) was 14 out of 15, which indicated he was cognitively intact. R1's incident report dated 10/12/23 at 7:00 p.m., indicated R1 and R2 made inappropriate and explicit comments to each other and continued to become more aggressive. The incident report indicated R1 and R2 had to be physically separated by staff and the police were contacted. A Minneapolis Police Department Report dated 10/12/23, indicated local law…

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.