Southside Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure staff completed mandatory resident rights training for 1 of 5 staff members (registered nurse (RN)-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on resident rights annually. Review of personnel records indicated that RN-B had not completed education that included resident rights in the last year. During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year. During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning her training for resident…

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 staff completed mandatory abuse/vulnerable adult training for 1 of 5 staff members (registered nurse (RN)-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on vulnerable adults/abuse annually. Review of personnel records indicated that RN-B had not completed education that included abuse/vulnerable adult training in the last year. During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year. During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed…

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 staff completed mandatory quality assurance and performance improvement (QAPI) training for 5 of 5 staff members (director of nursing (DON), registered nurse (RN)-A, RN-B, licensed practical nurse (LPN)-A, LPN-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on QAPI annually. Review of personnel records indicated that the DON, RN-A, RN-B, LPN-A, and LPN-B had not completed education that included QAPI in the last year before survey entrance. During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year. During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure staff completed mandatory infection control training for 1 of 5 staff members (registered nurse (RN)-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated that clinical staff were to receive training on infection control annually. Review of personnel records indicated that RN-B had not completed education that included infection control in the last year. During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year. During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning her training 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.

Based on observation, interview, and document review, the facility failed to ensure private and confidential resident information was secure and not visible to residents and staff members who did not require access, when documents were found stored in an unprotected manner. This had the ability to affect 9 of the 13 residents (R1, R2, R3, R4, R5, R7, R9, R10, R12) residing at the facility whose medical documents were found unprotected.Findings include: Basement During a continuous observation starting at 3/30/26 at 1:04 p.m., a staircase leading down to a small room was observed. On the left side of the small room were two desks and a small cabinet with a pile of paper that was approximately two feet high. The documents were reviewed and included documents for R1, R2, R3, R4, R5, R7, R9, R10, R12 as well as multiple discharged residents. The pile included documents such as resident order summary sheets and medication administration records, and the documents reviewed were dated from 6/2025 to 1/2026. On the right side of the room was a clothes washer and dryer, and various cleaning…

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 medications were stored in a manner to reduce the risk of unauthorized access for 5 of 5 residents (R1, R2, R3, R4, R5) observed to have medications stored in an unsecured facility refrigerator.Findings include:During an observation and interview on 4/1/26 at 9:21 a.m. in the facility dining room, a medication cart with a small mini refrigerator next to it was observed. The mini fridge was not observed to have a lock on it. Registered nurse (RN)-A stated that they stored medications that needed refrigeration in the small mini refrigerator. RN-A was observed to open the mini fridge door and show that they have a small lock box inside, but they did not use it now. No medications were observed inside the lock box. Inside the medication fridge, multiple boxes of medication were observed, including Copaxone (an injection medication used to treat multiple sclerosis), Ozempic (an injection medication used to treat diabetes), and Trulicity (an injection medication used to treat diabetes).During an 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.

Based on interview and document review, the facility failed to ensure recommended influenza and pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for all 13 residents reviewed for immunizations.Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated March 2025, identified several tables with corresponding recommendations for patient on when to receive various versions of the pneumococcal vaccine depending on their age and diagnoses. In addition, recommendations identified importance of shared clinical decision-making with their provider. During interview with director of nursing (DON) on 3/31/26 at 11:38 a.m., DON stated the facility did not have a process in place to document vaccination status of all residents. DON stated the residents were all mobile and we send them to Walgreens and ask for a copy [of their vaccination information]. DON reviewed resident paper charts and electronic medical records (EMR) of all 13 residents and stated they…

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

Based on interview and document review, the facility failed to establish and maintain documentation of COVID-19 vaccination status for all 13 residents of facility. In addition, facility failed to establish and maintain documentation of COVID-19 vaccination status for cook (CK)-B to include being offered and/or provided education regarding the benefits and potential risks associated with COVID-19 vaccination. This had the potential to affect all 13 residents and staff of facility.Findings include: Residents:During interview with director of nursing (DON) on 3/31/26 at 11:38 a.m., DON stated the facility did not have a process in place to document vaccination status of all residents. DON stated the residents were all mobile and we send them to [pharmacy] and ask for a copy [of their vaccination information]. DON reviewed resident paper charts and electronic medical records (EMR) of all 13 residents and stated they lacked immunization records. '[it is] hard to tell who needs a vaccine or not at this time. In addition, DON stated facility lacked documentation or messaging to providers…

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 and interview, the facility failed to reasonably accommodate resident preference for a private and usable space for R6 who shared a room.Findings include:R6's quarterly MDS dated [DATE], indicated intact cognition and was independent with most personal cares. In addition, R6 gad diagnoses of depression, diabetes, anxiety, and post-traumatic stress disorder.During observation on 3/30/26 at 1:15 p.m., R6 was lying in his bed in his two-person room. R6's twin sized bed was located inside the door frame to the hallway. The bed was parallel to and against the North wall of room. The footboard of his bed was against a closet which extended from North wall by 20 inches. A privacy curtain attached to the ceiling started at the closet above the foot of his bed and draped around a dresser which measured 18 inches deep by 30 inches long. The curtain was pulled out to encompass the dresser and then immediately parallel and against R6 bed to the head of his bed and [NAME] wall. There was no carpet or floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to immediately report incidents of potential resident-to-resident abuse to the state agency (SA) within two hours, as required for 2 of 2 residents (R2, R8) reviewed for abuse.Findings include:R2R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated the Brief Interview for Mental Status (BIMS) was completed, and R2 had a score of 15/15, indicating intact cognition.R2's quarterly MDS dated [DATE], indicated R2 was admitted to the facility on [DATE]. The MDS indicated that the BIMS and the staff assessment for mental status were not completed. The MDS indicated R2 was diagnosed with anxiety and depression.R2's progress notes were reviewed and lacked an indication that R2's allegations of resident-to-resident abuse were reported to the SA.R8R8's admission MDS dated [DATE], indicated that R8 had intact cognition and had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) one to three…

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 complete and comprehensive Minimum Data Set(s) (MDS) were completed for 1 of 5 residents (R7) reviewed for assessment accuracy.Findings include:The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified the MDS as an assessment tool that facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. The CMS RAI manual also identified that the RAI process (i.e., MDS) was completed to help evaluate residents' strengths and areas for care planning.R7's annual MDS dated [DATE], included the following information:-Section C- Cognitive Patterns: indicated C0100 (Should Brief Interview for Mental Status (C0200-C0500) be Conducted?) was not assessed, as well as Sections C0200 through C1310, fields regarding mental status, memory, cognitive skills, and signs 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 that quarterly Minimum Data Set(s) (MDS) were completed in a thorough manner for 2 of 5 residents (R1, R2) reviewed for assessment accuracy.Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified the RAI consists of three basic components, including the MDS, the Care Area Assessment (CAA), and the utilization guidelines and this process (i.e., use of the entire RAI) was mandated by CMS. The manual outlined that a quarterly assessment was a non-comprehensive assessment which was to be completed every 92 days and was used to track a resident's status between comprehensive assessments . to ensure critical indicators of gradual change in a resident's status are monitored. The manual included a section labeled, SECTION C: COGNITIVE PATTERNS, which outlined how the section would be used to help determine the resident's attention,…

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 for 2 of 5 residents (R1, R3) reviewed for MDS accuracy.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 for 2 of 5 residents (R1, R3) reviewed for MDS accuracy.Findings include:R1's quarterly MDS dated [DATE], indicated under Section I: Active Diagnoses, that R1 did not have a diagnosis of non-Alzheimer's dementia.R1's Diagnosis Report dated 12/22/25, indicated R1 had a diagnosis of vascular dementia added on 12/22/25.R1's provider note dated 12/8/25, indicated R1 had a diagnosis of vascular dementia, and there had been some progression of this dementia.R3's quarterly MDS dated [DATE], indicated under Section N - Medications, that R40 had received 1 day of insulin…

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 timeliness of person-centered care conferences for 3 of 3 residents (R2, R4, R6) and to include periodic review and revision by an interdisciplinary team along with the residents in adjusting their care plan and making decisions about their care.Findings inclide: R2's quarterly MDS dated [DATE], indicated the BIMS was completed, and R2 had a score of 15/15, indicating intact cognition. R2's quarterly MDS dated [DATE], indicated R2 was admitted to the facility on [DATE]. The MDS indicated that the BIMS and the staff assessment for mental status were not assessed. R2's medical record was reviewed, and the last care conference note was dated 8/21/25. During an interview on 3/30/26 at 6:05 p.m., the administrator confirmed the note from 8/21/25 was the most recent care conference note he could find for R2. During an interview on 4/1/26 at 1:05 p.m., R2 stated she did not recall being offered or attending a care conference in the last 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 observation, interview, and document review the facility failed to provide routine dental services to 2 of 2 residents (R3, R4) reviewed for dental services. Findings include: R3R3's face sheet identified R3 admitted to facility on 4/10/2020.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 with intact cognition, did not reject care, was independent with personal and oral hygiene, and diagnoses of schizoaffective disorder, bipolar, diabetes, anxiety, and epilepsy.R3's Care Area Assessment (CAA) dated 3/21/25 identified R3, Teeth show obvious cavities and missing most of upper teeth and triggered a dental care plan due to medications, unstable diabetes,R3's care plan (CP) dated 4/18/20, identified, PERSONAL HYGIENE/ORAL CARE: The resident requires supervision to assistance of 1 PRN to complete hygiene cares and The resident has potential for oral/dental health problems r/t Poor oral hygiene. In addition, CP intervention state, Coordinate arrangements for dental care, transportation as…

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

Based on interview and document review, the facility failed to employ a registered dietician or other active qualified clinical nutrition professional to carry out the functions of a facility registered dietician. This had potential to affect 11 of 11 residents who received food from the kitchen. Findings include: When interviewed on 1/27/25 at 12:07 p.m., cook (C)-B, who was the head cook, stated eggs were on the menu every day, but they did not serve eggs every day. C-B stated other cooks did not follow the menu which made ordering and using items before perishing more difficult. C-B stated they had one resident who was a vegetarian; otherwise, the other residents were on a regular house diet. When asked about the registered dietician's involvement, C-B stated they thought the registered dietician quit and did not come to the facility anymore. When interviewed on 1/27/25 at 1:24 p.m., registered nurse (RN)-A, who was the facility administrator and director or nursing, stated they had a newly-hired dietician, and the new dietician had not been as involved as the previous one. RN-A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service, and ensure food was properly stored and dated and disposed of. Furthermore, the facility failed to ensure staff followed appropriate infection control techniques while rinsing dirty dishes, placing clean dishes to dry, and placing items into the refrigerator. This deficient practice affected all 11 residents residing in the facility. Findings include: During the initial tour of the kitchen on 1/27/25 at 12:04 p.m., cook (C)-B, who was the head cook, had gloves on and rinsed dishes in the sink, placed silverware and serving trays into the dish machine, and removed gloves and did not perform hand hygiene. The dish machine ran, and the wash temperature fluctuated between 141 to 144 degrees Fahrenheit (°F) and the rinse temperature raised to 178°F . C-B stated the temperature of the dish machine fluctuated, and the dish machine was fixed multiple times. C-B…

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 administration failed to provide adequate oversight, training, and guidance for appropriate resident care related to accurate Minimum Data Set (MDS) Assessments, qualified staff and related services, the pre-admission screen and resident review (PASARR) process, and Quality Assurance and Performance Improvement (QAPI) plan and Quality Assurance and Assessment (QAA) committee requirements. This deficient practice had the potential to affect all 11 residents residing in the facility, potential new admissions, visitors, and employees of the facility. Findings include: QUALIFIED STAFF AND RELATED SERVICES ADMINISTRATOR Per Southside Care Center Nursing and Administrator Coverage policy and procedure updated 12/5/24, the administration would have addressed all the proposed plans of correction (POC) to ensure consistent compliance with both state and federal regulations for nursing facilities and would audit these corrective actions throughout the QAPI process. Furthermore, the policy indicated the facility's administration would…

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

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Q4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: Review of the facility's payroll based journal (PBJ) staffing data report dated 7/1/24 - 9/30/24 (Q4), identified the facility failed to have licensed nursing coverage 24 hours/day for the following dates: 7/3/24, 7/6/24, 7/7/24, 7/12/24, 7/13/24, 7/14/24, 7/19/24, 7/20/24, 7/28/24, 7/29/24, 7/30/24, 8/1/24, 8/2/24, 8/3/24, 8/4/24, 8/5/24, 8/6/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/16/24, 8/17/24, 8/18/24, 8/20/24, 8/23/24, 8/24/24, 8/25/24, 8/27/24, 8/28/24, 8/30/24, 8/31/24, 9/1/24, 9/2/24, 9/3/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, 9/10/24, 9/11/24, 9/14/24, 9/15/24, 9/20/24, 9/21/24, 9/22/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, and 9/30/24. The facility's schedule dated 7/1/24 - 7/15/24 indicated they did have licensed nursing…

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 implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement. Additionally, facility failed to identify and prioritize problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicators, and resident and staff input. Furthermore, the facility failed to ensure governing body oversight of the facility's QAPI program and activities. This deficient practice had the potential to affect all 11 residents residing in the facility. Findings include: An undated facility policy titled Quality Assessment and Assurance program (QAA) indicated the facility would maintain a QAA committee which would meet quarterly, and its purpose was to develop an on-going quality assurance program through an interdisciplinary approach and assess the effectiveness of the health care provided to the residents. The policy indicated the structure…

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

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to Minimum Data Set (MDS) assessment inaccuracies, activities, trauma-informed care, food sanitation, and failure to implement a QAPI plan and maintain a QAPI committee with improvement projects which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all residents residing in the facility. Findings include: A review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report (a quality measure report for nursing facilities) last updated 1/22/25, indicated the facility had the following deficiencies with a survey exit date of 11/30/23: - F641 Accuracy of Assessments - F679 Activities Meet Interest/Needs of Each Resident - F699 Trauma-Informed Care - F812 Food Procurement, Store/Prepare/Serve Sanitary - F865 QAPI…

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

Based on interview, and document review, the Quality Assurance (QA) committee failed to ensure required members of the committee attended the quarterly meetings. This had the potential to affect all 11 residents who resided at the facility. Findings include: An undated facility policy titled Quality Assessment and Assurance program (QAA) indicated the facility would maintain a QAA committee which would meet quarterly, and the structure of the committee would consist of the administrator, the medical director, director of nursing (DON), program director, and consulting pharmacist. The policy further indicated the objective of the QAA program was the ensure compliance with standards and regulations and other staff and/or individuals may be asked to attend the meetings by request of the committee. The facility's Quality Assurance Meeting sign-in sheets dated 1/8/24, 4/8/24, 7/8/24, 10/7/24, and 1/13/25 were reviewed on 1/31/25 at 1:47 p.m. and revealed the medical director had not signed in for any QAA meetings. The sign-in sheets further identified registered nurse (RN)-A identified…

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

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were maintained during laundry services. This had potential to affect all 11 residents who resided in the facility. Findings include: During observation and interview on 1/28/25 at 8:05 a.m., housekeeping (HK)-D, who was also the head of housekeeping and laundry services, wore gloves and no gown to put laundry detergent and Clorox Bleach into the washer machine, took linens and bed sheets from a bag on the floor and placed them into the washer machine in multiple loads, and closed the washer machine. HK-D folded clean washcloths with the same gloves. HK-D stated they do not need to wear a gown to load dirty linen and clothes into the washer machine. HK-D verified they used the same gloves to load the dirty laundry and fold the clean washcloths. When interviewed on 2/3/25 at 10:09 a.m., registered nurse (RN)-A, who was the administrator and director of nursing, expected staff to wear gloves to handle soiled laundry and change gloves and perform hand hygiene prior 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.

Based on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This deficient practice had the potential to affect all 11 residents residing in the facility. Findings include: After reviewing the facility documents, no certification for Infection Preventionist was revealed. On 1/28/25 at 9:04 a.m., director of nursing (DON) stated he was currently the acting facility infection preventionist and was responsible for overseeing the infection control program. DON verified he had not completed specialized training for infection prevention and control. and no staff were currently enrolled in any specialized training at this time nor had any specialized infection control education scheduled. A facility policy titled Infection Preventionist, revised 7/2024, indicated the following: Policy Interpretation and Implementation 1. The facility's infection control policies and procedures apply to all personnel, consultants, contractors, residents, visitors, volunteer workers 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 the Minimum Data Set (MDS) was accurately coded for 5 of 7 residents (R1, R6, R7, R10, R11) reviewed for inaccurate MDS assessments. Findings include: R1 - Activity Preferences R1's annual Minimum Data Set (MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS, or an assessment to determine a person's mental status) score of 11, indicating mild cognitive impairment. Additionally, the MDS indicated she had clear speech with the ability to make herself understood and was able to understand others. The MDS reported the interview for daily and activity preferences should not be conducted because R1 was rarely/never understood and family/significant other was not available. The MDS indicated staff assessed R1 regarding her daily and activities preferences and identified R1 preferred participating in her favorite activities and doing things in groups of people. The MDS identified diagnoses of anxiety, bipolar disorder…

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 level II pre-admission screen and resident review (PASARR) was completed prior to admission for 4 of 5 residents (R7, R9, R10, R11) reviewed who required a level II PASARR screening for mental illness. Findings include: R7: R7's admission Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and no hallucinations or delusions with no reported behavioral symptoms. The MDS reported diagnoses including depression and alcohol dependence. Additionally, the MDS reported R7 was not currently considered by the state level II preadmission screening and resident review (PASARR) process to have serious mental illness and/or intellectual disability or a related condition. An admission record dated 11/13/24, indicated R7 admitted to the facility on [DATE]. R7's Minnesota Senior Linkage Line preadmission screening results dated 11/21/24, identified a Level II assessment for mental illness was required prior to her admission to 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 serve food according to a menu, and review changes to a menu with a qualified dietician or other qualified nutrition professional. In addition, the facility failed to ensure the menu met the nutritional needs of residents with a cardiac diet and other diets for 5 of 5 residents (R1, R2, R3, R5, R10) reviewed for dietary recommendations. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had mild cognitive impairment. The MDS identified diagnoses of diabetes mellitus, hyperlipidemia (condition where there are high levels of fats in the blood), anxiety, bipolar disorder (a chronic mental health disorder characterized by extreme mood swings between extreme periods of elevated moods, or mania, and extreme low moods, or depression), schizophrenia (a chronic mental health illness that affects a person's thoughts, perceptions, emotions, and behaviors), and mild intellectual disabilities (a developmental disorder…

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 comprehensive assessment was completed and implemented using the Resident Assessment Instrument (RAI) process as specified by CMS for 1 of 3 (R7) residents reviewed for trauma-informed care in addition to 1 of 5 residents (R7) reviewed for psychotropic medications. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and no hallucinations or delusions with no reported behavioral symptoms. The MDS reported diagnoses including depression and alcohol dependence, however, did not identify a post-traumatic stress disorder (PTSD) diagnosis. The MDS reported R7 took antidepressant medications and antipsychotic medications on a routine basis only. R7's Care Area Assessment (CAA) for psychosocial well-being dated 11/7/24, indicated R7 reported feeling lonely and that her mood and/or behavior impacted her interpersonal relationships or arose from social isolation. The CAA identified R7 took…

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 coordinate assessments with the pre-admission screening and resident review (PASARR) program by incorporating recommendations from the PASARR level II determination and the PASARR evaluation report into the care plan for 1 of 6 (R6) reviewed for PASARRs. Findings include: R6's modification of annual Minimum Data Set (MDS) dated [DATE], indicated she was not currently considered by the state to have serious mental illness and/or intellectual disability or a related condition. The MDS indicated she had intact cognition, did not exhibit physical or verbal behaviors directed towards herself or others, but did report hallucinations and delusions during the lookback period. R6's MDS included diagnoses of schizophrenia (a chronic mental health illness that affects a person's thoughts, perceptions, emotions, and behaviors), alcohol dependence in remission, insomnia (a sleeping disorder), history of cocaine abuse, and encephalopathy (a medical condition that…

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 review and revise the activities care plan with input from the resident and/or resident representative for 1 of 1 residents (R1) reviewed for activities. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS, or an assessment to determine a person's mental status) score of 11, indicating mild cognitive impairment. Additionally, the MDS indicated she had clear speech with the ability to make herself understood and was able to understand others. The MDS reported the interview for daily and activity preferences should not be conducted because R1 was rarely/never understood and family/significant other was not available. The MDS indicated staff assessed R1 regarding her daily and activities preferences and identified R1 preferred participating in her favorite activities and doing things in groups of people. The MDS identified diagnoses of anxiety, bipolar disorder (a chronic mental health…

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 evaluate a resident's discharge needs or develop a discharge plan to ensure an appropriate discharge location could accommodate resident medical, mental health, oncology, cancer care, and medication needs for 1 of 1 residents (R12) who was discharged to a location where it was unknown if they could meet R12's needs. Findings include: R12's discharge return not anticipated Minimum Data Set (MDS) dated [DATE], indicated R12 had a planned discharge to a home/community setting, had intact cognition, mild depression, no behaviors, and was independent with activities of daily living. The MDS identified diagnoses of major depressive disorder, alcohol dependence, adjustment disorder with depressed mood, history of suicide attempt, and a history of other psychoactive substance abuse. The MDS indicated antipsychotic and antibiotic medication use. The MDS indicated there was not an active discharge plan in place for R12 to return to the community, and R12 did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 1 residents (R1) reviewed for activities. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS, or an assessment to determine a person's mental status) score of 11, indicating mild cognitive impairment. Additionally, the MDS indicated she had clear speech with the ability to make herself understood and was able to understand others. The MDS reported the interview for daily and activity preferences should not be conducted because R1 was rarely/never understood and family/significant other was not available. The MDS indicated staff assessed R1 regarding her daily and activities preferences and identified R1 preferred participating in her favorite activities and doing things in groups of people. The MDS identified diagnoses of anxiety, bipolar disorder (a chronic mental health disorder characterized by extreme mood…

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 blood pressure monitoring and order was in place for 1 of 5 residents (R3) observed during morning medication administration. Findings include: R3's annual Minimum Data Set (MDS) dated [DATE], indicated R3 had intact cognition, delusions, and no behaviors or rejection of care. The MDS indicated R3 was independent with activities of daily living, had diagnoses of orthostatic hypotension (drop in blood pressure when standing up or sitting down), hyperlipidemia (condition where there are high levels of fats in the blood), depression, and schizophrenia, and medications included antipsychotics and antidepressants. R3's medication and treatment administration record for January 2025, indicated R3 had the following orders: -9/13/23, Midodrine HCL 2.5 milligram (mg) tablet and instructed staff to give [ONE] [TABLET] BY MOUTH TWICE DAILY - HOLD FOR B/P [blood pressure] 110 MMHG [MILLIMETERS OF MERCURY] BUT GIVE IF [R3] IS…

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 triggers to avoid potential re-traumatization and failed to develop and implement the comprehensive care plan to include individualized trauma-informed approaches for 1 of 2 resident (R7) who had a history of trauma. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and no hallucinations or delusions with no reported behavioral symptoms. The MDS reported diagnoses including depression and alcohol dependence, however, did not identify a post-traumatic stress disorder (PTSD) diagnosis. R7's Care Area Assessment (CAA) for psychosocial well-being dated 11/7/24, identified R7 took psychotropic medications mirtazapine and fluoxetine (antidepressants) to treat depression. Additionally, the CAA identified she utilized non-pharmacologic interventions such as crafting activities, sitting outside on the front porch, smoking cigarettes, and minimal socializing to manage anxiety symptoms. The CAA…

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 PRN (as needed) psychotropic medication order included an end date or a documented clinical rationale for 1 of 1 residents (R7) reviewed for PRN psychotropic medications. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and no hallucinations or delusions with no reported behavioral symptoms. The MDS reported diagnoses including depression and alcohol dependence. The MDS reported R7 took antidepressant medications and took antipsychotic medications on a routine basis only. R7's Care Area Assessment (CAA) for psychotropic drug use dated 11/7/24, identified she took an antidepressant, a mood stabilizer, and scheduled antipsychotic medication, however, lacked documentation of her as needed (PRN) antipsychotic medication. R7's signed order summary was requested but not received. R7's medication administration record (MAR) dated 1/25 reflected the following active physician orders: -…

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

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours per day. This deficient practice had the potential to affect all 13 residents who resided in the facility. Findings include: Review of the facility Staffing Schedules dated 10/1/2023, through 11/30/23, revealed the facility lacked eight hours of RN coverage for the following dates in 2023: 10/1, 10/7, 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, 11/5, 11/11, 11/12. 11/18, 11/19, 11/25, 11/26. Review of the Southside Care Center Weekly Staffing posting revealed the facility lacked RN hours on the following dates in 2023: 10/1, 10/7, 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, 11/5, 11/11, 11/12. 11/18, 11/19, 11/26. During interview on 11/29/23 at 2:49 p.m. the administrator stated they tried to hire staff, but it was difficult to find anyone who was willing to work weekends. They confirmed they did not have any staffing waivers, and the facility did not always have an RN on duty for eight hours each day.

Based on observation, interview and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and final rinse temperature (i.e., 150 degrees Fahrenheit (F) and 180 degrees F, respectively). This had the potential to affect all 12 residents within the nursing facility and staff who consumed food in the main production kitchen. Findings include: A facility document titled Dishwasher Temperature Logs dated 11/2023, indicated dishwasher temperatures were tracked after each meal. The log further indicated 14 of 29 days lacked any documentation of dishwasher temperatures. On 11/28/23 12:36 p.m., an initial kitchen tour was completed with cook (CK)-A present. A single Ecolab commercial dishwasher was located next to a two-sided sink. The dishwasher had two digital thermometer readouts on the door: one reading wash and one rinse. Hanging out of the top closed dishwasher door was a dripping-wet towel. Inside cabinet doors under…

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

Based on interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement. This deficient practice had the potential to affect all 13 residents residing in the facility. Findings include: The facility's QAPI - Quality Assurrance and Performance Improvement - Quality Assurance Assessment policy date 11/4/22, indicated the plan included the policies and procedures to: 1. Identify and use data to monitor our performance 2. Establish goals and thresholds for our performance measurement 3. Utilize resident and staff ideas for improvement 4. Identify and prioritize problems and opportunities for improvement 5. Systematically analyze underlying causes of systemic problems and adverse events 6. Develop corrective action or performance improvement activities The the above policies and procedures were requested but not provided. When interviewed on 11/30/23, at 4:58 p.m., the administrator stated QAPI meeting were held…

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

Based on document review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that was effective in identifying and responding to quality deficiencies, and developing procedures for feedback, data collection and monitoring systems. In addition, the facility failed to provide evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas. This deficient practice had the potential to affect all 13 residents currently residing in the facility. Findings include: Quality tracking data was requested from the facility but was not provided. The agendas for quality committee meetings 1/23 - 11/23, lacked identification adverse events and tracking of data-driven quality metrics or performance improvement projects (PIPs). During interview on 11/30/23 at 4:58 p.m., administrator stated a summary of care concerns was presented at QAPI meetings, however the facility did not track adverse events on a spreadsheet or by other means, and there was no method to monitor and track trends. They stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to implement their infection control program and prevent and control the onset and spread of COVID-19 to the highest extent possible when R10 tested positive for COVID-19. Furthermore, the facility failed to ensure transmission-based precautions (TBP) were initiated for 6 of 6 residents (R10, R6, R5, R9, R1, R2) who tested positive for COVID-19. This had the potential to impact all residents who reside in the facility. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact and had diagnoses of schizophrenia and anxiety. R10's nursing progress note dated 11/24/23, indicated R10 tested positive for COVID-19. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact and had diagnoses of schizophrenia and depression. R5's quarterly MDS dated [DATE], indicated R5 was cognitively intact and had diagnoses of schizophrenia and high blood pressure. R9's quarterly MDS dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure resident showers/bathtubs were sanitary for 1 of 2 resident bathrooms reviewed for a clean, homelike environment. R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact, ambulatory, and showered independently. During interview on 11/27/23 at 7:51 a.m., R13 stated the bathtubs in both bathrooms did not get cleaned right and sometimes the residents had to clean them themselves before using them. R11's annual MDS dated [DATE], indicated she was cognitively intact, ambulatory, and showered independently. During interview on 11/27/23, at 8:29 p.m., R11 stated the bathrooms were really gross, and things didn't seem to be sanitized. During observation on 11/28/23 at 5:05 p.m., the shower curtain liner in the upstairs bathroom was streaked with large areas of orange, white, and dark brown substances within the folds as it hung on the bar. A dark brownish-black substance was noted along the bottom edge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R12, R13) received education and were offered or received the pneumococcal vaccine in accordance with the Centers for Disease Control (CDC) recommendations. In addition, the facility failed to obtain educated consent or refusal for 5 of 5 residents (R1, R3, R11, R12, R13) who were offered the influenza vaccine at the facility. Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], included R1 was age [AGE], had a diagnosis of seizure disorder, and indicated R1 received the influenza vaccine outside the facility and was not up to date with Pneumococcal vaccination due to a medical contraindication. R1's History of Communicable Diseases form indicated R1 had the PPSV23 vaccination on 9/29/21, and the influenza vaccine on 10/2/23. The CDC's PneumoRecs VaxAdvisor indicated for patients aged 65 and over who have not received PCV15 or PCV20, had a PPSV23 and did not have a PCV13, Give one dose of PCV15 or PCV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to assess residents for the ability to self administer medications for 2 of 2 resident (R5 and R6) reviewed for medications at bedside. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and had diagnoses of schizophrenia and depression. R6's medication administration record (MAR) dated 11/2023, indicated a scheduled morning medication pass of the following: -escitalopram oxalate 10 milligrams (mg) tablet (Lexapro) for depression. -fiber unboxed 625mg tablet (Fibercon) for constipation. -molnupiravir 800mg capsules (Lagevrio) for coronavirus 19 (COVID-19) infection. -midodrine hydrochloride (hcl) 2.5mg tablet (Proamatine) for low blood pressure. R6's treatment administration record (TAR) dated 11/2023, indicates R6 required monitoring of medication compliance as resident tried to hide medication in mouth or hand instead of taking it. R6's care plan dated 5/01/22, indicated R6 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure completed Minimum Data Set (MDS) assessments were accurate for 3 of 5 residents (R2, R3, R13) reviewed for unnecessary medication. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had diagnoses of schizophrenia and major depressive disorder. R2's MDS further indicated R2 was taking antianxiety and antidepressant medications. R2's MDS lacked a completed and accurate patient health questioner-9 (PHQ-9) assessment (an assessment used to determine severity of depression and used to monitor response to treatment). R3's quarterly MDS dated [DATE], indicated R3 had mild cognitive impairment and diagnoses of bipolar disorder and anxiety. R3's MDS further indicated R3 was taking anti-psychotic medication. R3's MDS lacked a completed and accurate PHQ-9 assessment. R13's quarterly MDS dated [DATE], indicated R13 was cognitively intact and had diagnoses of bipolar disorder, depression and anxiety. R13's MDS further indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure individualized activities were provided for 2 of 2 residents (R11, R13) reviewed for activities. Findings include: R11's annual MDS dated [DATE], indicated they were cognitively intact and had a diagnosis of depression. R11 identified it was very important for her to do her favorite activities, and somewhat important to have reading material and do thing with groups of people. R11's care plan activity focus areas dated 11/20/22, indicated R11 did not want to participate in activities with interventions to modify daily schedule and treatment plan as needed to accommodate activity participation as requested by the resident, and identified R11's preferred activities were playing bingo, reading, listening to news in the morning, current events, watching football and reality television, and talking on the phone. R11's Care Conference Record dated 4/5/23, included preferred activities of medical appointments part-time work, friend…

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 comprehensively assess for and identify potential triggers to avoid re-traumatization for 1 of 1 resident (R13) who had a history of trauma. Findings include: R13's quarterly MDS dated [DATE], indicated she was cognitively intact, had diagnoses of post-traumatic stress disorder (PTSD), anxiety, depression, manic depression, psychotic disorder, and had delusions. The MDS identified R13 exhibited verbal symptoms (such as threatening, screaming, cursing) directed toward others daily, and often exhibited other behavioral symptoms such as self-injury and pacing on 1-3 of the previous seven days. R13 took antianxiety, antidepressant, hypnotic, antipsychotic, and opioid medications regularly. R13's Medical Diagnosis list printed 11/29/23, included (PTSD). R13's Care Area Summary dated 5/12/23, identified the Mood State and Behavioral Symptoms care areas were not triggered. R13's care plan revised 9/24/23, included mood and depression focus areas, however…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to assess for safety and appropriate use of bed rails, ensure alternate interventions were assessed and/or attempted, and failed to review risks and benefits of bed rails and obtain consent for 1 of 1 resident (R11) who was observed to have a bed rail affixed to their bed. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, used a walker and wheelchair for mobility, and were independent with bed mobility, standing, and transfers. R13 had diagnoses of high blood pressure, ankle fracture, anxiety, depression, bipolar psychotic disorder, and PTSD and lung disease. The MDS indicated bed rails were not in use. R13's care plan dated 9/4/23, lacked indication for the bed rail. R13's medical record lacked evidence of assessment for safety and use, discussion of risk and benefits, resident consent, and attempted alternatives prior to installation of the bed rail. During observation 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 assist 1 of 1 residents (R6) with denture pain to obtain an appointment for dental services. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had intact cognition and diagnoses of disorder of teeth and supporting structures. Furthermore, R6's MDS identified R6 had broken or loosely fitting dentures as well as mouth or facial pain and discomfort with chewing. R6's dental Care Area Assessment (CAA) indicated R6 had infrequent gum pain that was relieved by removing dentures and will be care planned to maintain current level of functioning and minimize decline. R6's care plan dated 6/4/21, identified gum pain secondary to dentures. Interventions included removal of dentures when experiencing pain and use of medication to relieve pain. Additionally, R6's care plan indicated to notify R6's dentist if pain did not resolve. R6's care plan also identified that R6 had the potential for oral/dental health problems…

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.