Benedictine Health Center Innsbruck

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure medication was discontinued according to physician's orders for 1 of 1 resident (R9) receiving an antibiotic. Furthermore, the facility failed to ensure side effect monitoring was in place for 1 of 1 resident (R35) receiving an anticoagulant (blood thinner). Findings include: R9R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated intact cognition and diagnosis of Prurigo nodularis (chronic skin condition characterized by intensely itchy, firm, raised nodules that often result from persistent scratching. R9's after visit summary dated 3/31/26, indicated a new order for Doxycycline 100 milligram (mg) capsule. Take 1 capsule (100 mg) by mouth two times daily for 10 days with meals. R9's physician's orders indicated to monitor adverse reaction to antibiotic every shift from 3/31/26-5/10/26. R9's care plan dated 4/15/26, indicated R45 was taking an antibiotic known as Doxycycline for Prurigo nodularis with an intervention to receive 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 record review and interviews the facility failed to update the care plan for 1 of 1 resident (R1) reviewed for communication.Findings include:R1' s undated face sheet, indicated R1 was Vietnamese, admitted on [DATE], was moderately cognitively impaired, and had the following diagnoses: intercranial hemorrhage, hemiplegia and hemiparesis (loss of use of one side of the body), chronic kidney disease, hypertension, aphagia and pain. R1's social services assessment dated [DATE], indicated R1's preferred language was Vietnamese.R1's Care plan reviewed on 2/3/25, lacked identification of or interventions related to language or communication needs.On 2/3/26 at 3:25p.m., upon entering the room R1 immediately requested to have an interpreter because they could not understand writer. Via translation, R1 stated they felt like the facility did not care for them. R1 did not understand what was happening with their care, or to them. They stated they did not know how to communicate with the facility staff which was…

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 proper hand hygiene practices for 2 of 2 residents (R62, R59) observed during personal cares. In addition, the facility failed to ensure appropriate room assignment for 6 of 10 residents (R26,R23,R136,R74,R12,R11) reviewed for transmission based precautions (TBP). Also, the facility failed to ensure consistent and appropriate personal protective equipment (PPE) use for 5 of 10 residents (R11,R12,R73,R76, R59) reviewed for TBP and staff handling soiled laundry. Findings include: Room Assignment From CDC website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and 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 observation and interview the facility failed to maintain dignity for 1 of 1 resident (R62) reviewed for dignity. R62's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting, was always incontinent of urine, and received a diuretic on routine basis. R62's care plan dated 4/25/25, indicated the potential for alteration of bowel and bladder related to a diagnosis of a neurogenic bladder and included an intervention of R62 requiring 2 person assistance to use the toilet upon rising in the morning, before and after each meal, bedtime, on night rounds, and as needed. R62 also required assistance with all toileting tasks and used brief/pads for incontinence protection indicating he was not able to reliably notify staff of his need to be toileted. During interview on 5/12/25 at 5:25 p.m. 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 personal privacy during activities of daily living (ADLs) was provided for 1 of 2 residents (R9) reviewed for privacy. Findings include: R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's care plan dated 4/14/25, indicated R9 had an alteration in ADLs and required assist of one with dressing, and grooming. R9's care plan dated 4/14/25, indicated R9 had an alteration in mobility and required assist of one with transfers and ambulating. R9's care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure resident specific target behavior monitoring for antipsychotic use and further failed to ensure a gradual dose reduction (GDR) of an antipsychotic for 1 of 4 residents reviewed (R9) for antipsychotic use. Findings include: R9's annual Minimum Data Set (MDS) dated [DATE], indicated R9 did not take an antipsychotic. R9's quarterly MDS dated [DATE], indicated R9 routinely took an antipsychotic and a GDR had not been attempted and the physician had not documented a GDR was clinically contraindicated. Further, did not have physical, verbal, or other behavioral symptoms, did not reject care, and did not wander. R9's quarterly MDS dated [DATE], indicated R9 routinely took an antipsychotic and a gradual dose reduction (GDR) had not been attempted. Further, the MDS indicated a GDR (gradual dose reduction) had not been documented by a physician as clinically contraindicated. Further, R9 did not have physical, verbal, or other behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide timely incontinence care for 1 of 1 resident (R62) reviewed for activities of daily living (ADL). Findings include: R62's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting, was always incontinent of urine, and received a diuretic on routine basis. R62's care plan dated 4/25/25, indicated the potential for alteration of bowel and bladder related to a diagnosis of a neurogenic bladder and included an intervention of R62 requiring 2-person assistance to use the toilet upon rising in the morning, before and after each meal, bedtime, on night rounds, and as needed. R62 also required assistance with all toileting tasks and used brief/pads for incontinence protection indicating he was not able to reliably notify…

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 Feeding Tube R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 was cognitively intact, was dependent on staff for all activities of daily living (ADLs), and required a FT for nutrition. R37's diagnoses included dysphagia (difficulty swallowing) and nutritional deficiency, R37's care plan dated 5/13/24, indicated R37 had swallowing difficulty related to severe esophageal dysphagia and required nutrition provided using a feeding tube through a G-tube. R37's care plan instructed staff to check residual every four hours, flush G-tube with water before and after medications, maintain FT materials, not allow formula to hang longer than eight hours at room temperature, and change set up daily. R37's provider orders included the following: -Diet: NPO (nothing by mouth) except small sips of water-4/17/25 -Diet: tube feeding 45cc per hour for 22 hours Novasource renal-5/13/25 -Ensure formula bag for enteral feed has time and date on bag. Discard formula and replace every 24 hours-10/29/22 -Hold tube…

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 R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. Further, R9's vision was adequate with glasses. R9's care area assessment (CAA) dated 4/14/25, indicated R9 triggered for falls due to needing assist with cares, mobility, toileting due to multiple diagnoses and received Seroquel for psychotic disorder with delusions, and Zoloft for depression. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's Active Orders form indicated the following orders: • 3/20/24, Seroquel (an antipsychotic) 25 milligram (MG) tablet orally daily at 4:00 p.m. • 1/2/25, hip protector on at all times every shift. •…

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 follow up on reported grievances in a timely manner for 1 of 2 residents (R9) reviewed for grievances. Findings include: See also F689 related to falls. R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. Further, R9's vision was adequate with glasses. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's care plan dated 4/14/25, indicated R9 had an alteration in ADLs and required assist of one with dressing, and grooming. R9's care plan dated 4/14/25, indicated R9 had an alteration in mobility and required 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.

Based on observation, interview, and document review the facility failed to ensure the daily cleaning schedule was followed in the kitchen. During observation on 5/12/25 at 12:05 p.m., the kitchen floor was visibly soiled with dirt, there were multiple footprints, food spills, it was sticky, and there were copious amounts of food particles pushed down into the grout of the floor. During observation and interview on 5/14/25 at 10:37 a.m., the kitchen floor was visibly soiled with dirt, there were multiple footprints, food spills, it was sticky, and there were copious amounts of food particles pushed down into the grout of the floor. The director of dining services (DDS) verified the floor was dirty and stated kitchen staff were responsible for mopping the floor daily. During interview on 5/14/25 at 11:04 a.m., dietary aide (DA)-A stated the dishwasher was responsible for mopping the kitchen floor every day and verified the floor was dirty stating It had been a while since it had been cleaned. During interview on 5/15/25 at 10:47 a.m., the administrator stated the kitchen 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.

Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly stored, labeled, and dated and disposed after expiration date. Furthermore, the facility failed to ensure the use of hair restraints. This deficient practice had the potential to affect all residents who receive food from the kitchen. Findings include: Food Storage: During the initial kitchen observation on 8/12/24 at 12:06 p.m., the refrigerator contained the following: • a gallon of 1% milk with a best by date of 8/11/24 and the dietician stated needed to be thrown out. Hair Restraints: During interview and observation on 8/12/24 at 12:23 p.m., cook (C)-A had uncovered facial hair and was preparing food in the Robot Coupe food processor and was observed not wearing a beard guard/restraint or net. At 12:25 p.m., the dietician verified C-A was not wearing a beard net and stated he should have one on and stated she would have to look at the policy. Kitchenettes: During the observation of the Villa kitchenette on 8/12/24 at 12:29 p.m., contained the following: • 1…

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 vitals signs were taken as ordered for 1 of 3 residents (R77) reviewed for antipsychotic medication use and the facility failed to ensure resident's weights were monitored as ordered for 1 of 1 residents (R82) reviewed for nutrition. In addition, the facility failed to monitor skin alterations for 1 of 1 resident (R4) with facial bruising and failed to administer medications per doctor's order for 1 of 1 resident (R65) who repeatedly did not receive scheduled medications due to sleeping. Furthermore, the facility failed to ensure skin assessments were accurately documented for 3 of 3 residents (R90, R36, R88) reviewed for non-pressure skin altercations. Findings include: R77 R77's quarterly Minimum Data Set (MDS) dated [DATE], indicated R77 had severe cognitive impairment and received antipsychotic medications. R77's diagnoses included dementia, Alzheimer's disease, edema, vertigo, and asthma. R77 required substantial to full…

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 behaviors of potential wandering were comprehensively assessed for 3 of 3 residents (R15, R4, R21) and failed to assess for resident safety in the community for 1 of 1 resident (R15). The facility further failed to implement care planned interventions for 1 of 1 resident (R77) who wanders. Findings include: R15's admission Minimum Data Set, dated [DATE], indicated R15's preferred language was Hmong, did not need an interpreter, had difficulty hearing in some environments such as when speaking softly or a noisy setting and required a hearing device, a brief interview for mental status (BIMS) should have been conducted, however was not conducted, did not have hallucinations or delusions, did not exhibit wandering behavior, and did not reject care. Additionally, R15 used a cane, required partial to moderate assistance with toileting, showering, upper and lower body dressing, hygiene, and donning/doffing footwear. R15 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (measures intended to prevent the spread of multidrug-resistant organisms ) were implemented for 2 of 3 residents (R83 and R24) observed for enhanced barrier precautions, and failed to ensure appropriate hand hygiene during assist with activities of daily living (ADLs) for 1 of 2 resident (R24). Last, the facility failed to ensure ice packs were stored separately from food storage in two unit refrigerators. This had the potential to impact the residents who resided on those units. Findings include: R83's admission Minimum Data Set (MDS) dated [DATE] indicated the use of an indwelling catheter (a thin, hollow tube that is inserted into the bladder through the urethra to collect and drain urine. R83's medical diagnosis form in the electronic medical record dated 7/16/2024 indicated the following diagnosis: Encounter for palliative care (comfort cares), acute cystitis with hematuria (a medical condition…

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 the dining room floor for 1 of 3 dining rooms was clean and sanitary. Findings include: During observation on 8/12/24 at 12:17 p.m., the dining room floor of the Villa unit had copious amounts of dried food and spilled liquids and was very sticky upon walking on it. During observation on 8/12/24 at 1:30 p.m., all the residents in the Villa unit were in the dining room waiting to go to McDonalds for lunch and the floor was observed to be visibly soiled and sticky. During interview on 8/13/24 at 7:49 a.m., licensed practical nurse (LPN)-A verified the dining room floor (Villa unit) was visibly soiled, had many areas of dried food/liquid spills, and was sticky. LPN-A stated housekeeping came every morning at 8:00 a.m. and mopped the floor. -At 9:37 a.m. environmental services (ES)-A finished mopping the dining room floor, put out wet floor signs, and left the unit. Surveyor observed numerous sticky spots and spills of juice that still remained on the floor. During observation and interview on 8/13/24 at…

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 and individualized care plan was developed for 1 of 3 residents (R88) reviewed for psychotropic medication use. Findings include: R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, metabolic encephalopathy (change in how the brain works due to an underlying condition), delirium related to known physiological condition (a temporary mental state characterized by confusion, incoherent speech, and hallucinations), and age-related cognitive decline. Furthermore, R88's MDS indicated R88 had received an antipsychotic medication. R88's care plan revised on 8/12/24 at 3:45 p.m., (after the start of survey) indicated R88 used quetiapine for delirium. Interventions included to administer medication as ordered, ask for a possible dose reduction every three months, and monitor for side effects. Interventions further included monitoring behaviors every shift and document. R88's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide routine showers for 1 of 1 residents (R90) reviewed for activities of daily living (ADLs). Findings include: R90's admission Minimum Data Set (MDS) dated [DATE], indicated R90 was cognitively intact and had diagnoses of cellulites (skin infection) of right lower limb, lymphedema (swelling from due to lymphatic system problem), and fracture of right foot 5th toe. R90's admission MDS further indicated R90 did not reject cares, required substantial assistance for lower body dressing, supervision or touching assistance for personal hygiene, and had not been assess for bathing showering assistance due to medical/safety concerns. R90's care plan dated 7/28/24, indicated R90 had difficulty with bathing related to decline in mobility, lymphedema, and leg wounds. Interventions included staff assist with bathing weekly. R90's nursing care sheet no date, provided at survey exit indicated R90's bath day was on Monday. R90's nursing order dated 7/25/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to implement a walking program as written to prevent potential decrease in mobility for 1 of 1 resident (R73) reviewed for walking programs. Findings include: R73's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified she had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15/15, and no behaviors or rejection of care. R73 had no hearing difficulty in normal conversation, had clear speech, responded adequately to simple, direct communication only, and may miss some part of a message but comprehended most conversation. Functional physical impairments of upper and lower extremities were present, a wheelchair was normally used, and a cane was not identified as having been used. R73's walking ability was left blank, however she required partial to moderate assistance for chair to bed transfers, sit to stand and sit to laying down and was independent with wheelchair mobility. Diagnoses included stroke and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 1 (R47) resident reviewed who had post-traumatic stress disorder (PTSD) symptoms. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and was dependent on staff for eating, lower body dressing, and toileting assistance. Required substantial to maximal assistance with shower, bathing, and upper body dressing. Diagnoses included depression and bipolar disorder. R47's Activities of Daily Living (ADL) Care Area Assessment (CAA) worksheet dated 1/16/24, identified psychosocial well-being triggered due to six or more activities flagged as not important at all. R47 was admitted to skilled nursing facility with bipolar disorder and had a diagnosis of depression so changes in mood was expected. R47's trauma screening dated 1/20/22, identified she had been through life threatening…

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 assistance to a family member with determining mental capacity for 1 of 1 resident (R15) reviewed for social services. Findings include: R15's admission Minimum Data Set, dated [DATE], indicated R15's preferred language was Hmong, did not need an interpreter, had difficulty hearing in some environments such as when speaking softly or a noisy setting and required a hearing device, a brief interview for mental status (BIMS) should have been conducted, however was not conducted, did not have hallucinations or delusions, did not exhibit wandering behavior, and did not reject care. Additionally, R15 used a cane, required partial to moderate assistance with toileting, showering, upper and lower body dressing, hygiene, and donning/doffing footwear. R15 required partial to moderate assist with sitting to standing safely and required supervision or touching assistance to ambulate 10 feet. R15 was incontinent of bowel and bladder, had an anxiety…

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 provider's response to the initial medication review was followed and failed to ensure monitoring was in place for 1 of 3 residents (R88) reviewed for antipsychotic medication use. Findings include: R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, metabolic encephalopathy (change in how the brain works due to an underlying condition), delirium related to known physiological condition (a temporary mental state characterized by confusion, incoherent speech, and hallucinations), and age-related cognitive decline. Furthermore, R88's MDS indicated R88 had received an antipsychotic medication. R88's interim medication regimen review dated 7/20/24, indicated a pharmacist recommendation to the physician was sent. The recommendation stated R88 was taking the antipsychotic medication quetiapine for delirium however lacked an allowable diagnosis to support use. The recommendation included a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 3 residents (R88) who received antipsychotic medications had an appropriate indication and diagnoses for the medication. Furthermore, the facility failed to ensure staff were monitoring resident behaviors related to the antipsychotic medication and utilizing non-pharmacological approaches to ensure the antipsychotic medication was necessary. Findings include: R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, metabolic encephalopathy (change in how the brain works due to an underlying condition), delirium related to known physiological condition (a temporary mental state characterized by confusion, incoherent speech, and hallucinations), and age-related cognitive decline. Furthermore, R88's MDS indicated R88 had received an antipsychotic medication. R88's hospital Discharge summary dated [DATE], indicated recommendations for the outpatient provider. The recommendation was to consider…

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 care planned interventions to prevent worsening of existing pressure ulcers for 1 of 3 residents (R4) reviewed with a pressure ulcer. Findings include: R4's Resident Face Sheet indicated admission to facility on 8/3/23. The face sheet indicated diagnosis that included dementia, anxiety, muscle weakness and a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister) pressure ulcer. R4's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed no behaviors. The MDS indicated R4 was dependent on staff for putting on and taking off footwear and identified an unstageable (a full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [dead tissue] in the wound bed) pressure ulcer. R4's care plan…

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 demonstrate root cause analysis, failed to perform ongoing analysis and failed to implement individualized interventions to reduce the risk for falls for 1 of 3 resident (R5) who sustained multiple falls since admission to the facility. Findings include: R5's Resident Face Sheet indicated she admitted to the facility on [DATE], with diagnosis that included failure to thrive, weakness, cognitive deficits and a history of falls. R5's Observation Detail List Report dated 3/13/24, indicated she was alert and oriented, had adequate vision and required the use of assistive devices, impaired mobility and/or assist with toileting. Medication use included antihypertensives. History of falls in the last three months indicated none. Fall risk score was seven which indicated R5 was not at risk for falls. Observation Detail List Report dated 3/30/24, indicated R5 sustained one to two falls in the past three months and indicated a score of 9 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 3 residents (R2) reviewed for activities of daily living. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and R2 required moderate assistance with personal hygiene (helper does less than half the effort). R2's Diagnosis List printed 3/11/24, indicated diagnoses of dementia and muscle weakness. R2's Provider Order dated 1/26/24, directed staff to provide R2 with feeding assistance for meals three times daily. R2's care plan dated 10/10/23, indicated R2 required assistance with grooming and bathing. On 3/8/23 at 1:03 p.m., R2 was observed in his wheelchair in the dining room. R2's clothes were soiled with white substance splattered on his pajama pants, and food stains on his shirt. R2's fingernails were also observed to be dirty, with brown substance under them. On 3/8/24 at 2:19 p.m.,family member (FM)-A stated R2 would not have…

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 the comprehensive care plan that included interventions to assist with eating for 1 of 3 residents (R2) reviewed for activities of daily living. Findings include: R2's significant change Minimum Data Set, dated [DATE] indicated R2 had severe cognitive impairment. R2's Provider Order dated 1/26/24 directed R2 to receive feeding assistance for meals. R2's care plan dated 10/10/23 indicated R2 had inadequate oral intake related to a history of poor appetite and impaired cognition, and R2 required assistance for meal with supervision and encouragement. On 3/8/24 at 4:12 p.m., R2 was observed in the dining room. At the table there was milk, water, an empty jello bowl (which R2 had consumed) and a plate that contained corn, fish, and potatoes. A nursing assistant opened R2's tartar sauce and buttered the bun on his plate. R2 attempted to eat one bite of corn and it dropped down the front of himself. R2 ate his bun, drank his water…

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 quarterly interdisciplinary team (IDT) care conferences for 1 of 5 residents (R6) reviewed for care plan timing and revision. Findings include: R6's quarterly MDS dated [DATE], indicated R6 had severe cognitive impairment. R6's medical record indicated quarterly care conferences were held on 3/23/23 and 6/22/23. No care conferences had been held since that time. On 3/11/23 at 2:29 p.m., registered nurse (RN)-C stated the facility typically performed a care conference for each resident the first week after admission, quarterly, and as needs arose. RN-C acknowledged R6 missed several care conferences. On 3/11/24 at 3:24 p.m., the social worker (SW)-A stated, We have recently had some changes, and one employee didn't work out, partly because she wasn't having and documenting care conferences. SW-A further acknowledged there were no notes for R6's care conferences after 6/22/23, and no care conferences were scheduled for R6. SW-A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure nail care and feeding assistance was provided for 1 of 3 residents (R2) reviewed for activities of daily living (ADLs). Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], indicated R2 had severe cognitive impairment, required supervision for eating, and moderate assistance with personal hygiene. R2's Provider Order dated 1/26/24, directed staff to provide feeding assistance for meals three times daily. R2's Provider Order dated 1/19/24, directed R2's bath day was Friday, and Licensed nurse to complete body audit on resident bath day and document nail[s] in task. R2's care plan dated 10/10/23, indicated R2 required assistance for meal with supervision and encouragement. On 3/8/24 at 1:05 p.m., registered nurse (RN)-A stated R2 used to eat independently but now required assistance. RN-A stated, We encourage [R2] and sometimes have to just get [R2] get started [to eat.]. [R2] doesn't have the appetite he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed follow safeguards in place to ensure residents received the correct medications for 1 of 3 residents (R4) reviewed for medication error. Findings include: R4's Medicare 5-Day Minimum Data Sheet (MDS) dated [DATE] indicated R4 was cognitively intact. R4's Diagnoses List printed 3/11/24, indicated R4 had a diagnosis of glaucoma in both eyes. R4's Provider Orders dated 8/29/23, indicated brimonidine drops (used to lower pressure in the eyes related to glaucoma), 0.2%, administer one drop in each eye twice daily. R4's care plan printed dated 8/30/23, indicated administer medications per doctor's order. On 3/11/24 at 10:22 a.m., R4 stated on 9/7/23, she administered her own eye drops that were left on her tray table by licensed practical nurse (LPN)-A. R4 stated she then discovered they were for someone else. R4 stated the nurse notified the provider, and R4's own eye drops were held for one dose as a result. R4 denied any ill effects from using…

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.