The Villas At New Brighton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to develop care plans for 2 of 3 residents (R2, R3) reviewed for baths/ showers. R2 and R3 refused baths/showers and their care plans did not include interventions for refusals. Findings include: R2's quarterly MDS dated [DATE] indicated intact cognition, paralysis on one side of the body related to stroke, was fully dependent upon staff assistance for bathing, and identified no refusals of bathing/showering. R2's care plan dated 7/7/23 indicated a self-care deficit related to stroke and left-sided weakness, had a history of refusing ADLs, and starting 7/12/23 required assistance of one staff for bathing/showers. The care plan lacked interventions for refusal of bathing and/or showers. R2's Weekly Skin Assessments dated 1/26/26, 2/2/26, 2/9/26, indicated R2 refused showers. During an interview on 2/20/26 at 3:55 p.m., NA-A stated R2 refused showers frequently, but did not know why. NA-A stated staff should offer another shower time when R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 resident (R4) observed with medications at their bedside.Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses which included femur fracture, severe obesity, and asthma. R4's self-administration of medication evaluation dated 2/3/25, indicated ok to leave medication after nurse set up. In the section, the resident was able to demonstrate to the satisfaction of the nurse manager or designee, the assessment boxes indicated for the ability to produce all currently used medication containers and that these reflect the current physician-prescribed medications and all medications are stored properly (if stored in resident's room) was not checked.R4's current provider order list dated 9/10/25, lacked orders for Tums (calcium carbonate [used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report to the State Agency (SA) a serious bodily injury that resulted from the improper use of a full mechanical lift for 1 of 4 residents (R1) reviewed for falls.Findings include:The Minnesota Adult Abuse Reporting Center did not contain any facility reported incidents related to R1's reported fall from full mechanical lift with subsequent femur fracture on 8/29/25.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses which included colon cancer, fracture of left humerus and hemiplegia.Nursing progress notes identified on 8/29/25 at 9:45 p.m., 2 staff members were transferring R1 from his bed to a shower chair with a full mechanical lift. During the transfer, one loop of the sling handle came off of the lift hook, R1's right leg slid out of the sling and R1 landed on the floor in a sitting position then ended on his back. The administrator, director of nursing and on-call provider were notified. R1 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 record review the facility failed to provide a dignified living existence for 3 of 3 residents (R1, R2, and R3) reviewed. Staff failed to respond timely to the residents, leaving them incontinent of stool in their beds while waiting on staff assistance. Findings include: Upon observation and interview on 8/4/25 at 10:35 a.m. R1 was lying on her back in her bed. R1's room smelled of bowel movement (BM) odor. R1 stated she had a BM, turned on her light at approximately 9:00 a.m. A nursing assistant (NA) came into her room, turned off the light and had not returned. R1 stated that was the practice every morning. R1 stated she felt inhuman sitting in her own feces every morning. At 10:39 a.m. R1 put on her call again. At 10:43 NA-A came into her room, turned off her call light and stated she would go the other NA to assist her. At 10:48 a.m. NA-A and NA-B returned to assist R1. NA-A and NA-B changed R1's incontinent brief that consisted of wet BM saturated into the incontinent…

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 submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarter (Quarter 2) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 78 residents at the facility. Findings include: Payroll Based Journal (PBJ), [NAME] Report 1705D indicated the facility had excessively low weekend staffing during quarter 2 of fiscal year 2025, which included dates between January 1 to March 31st. Daily staff schedules during quarter 2 indicated adequate staff on weekends. During interview on 6/12/25 at 2:36 p.m. the regional director of operations stated she was just found out about the report indicating the 2nd quarter weekend staffing levels were low. She was going to analyze the cause. She believed it could have been if bonuses were offered, if on-call nurse managers were brought into the cover shift or the use of pool staff. She was not certain why the staffing levels were triggered. The Administrator 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 interview and document review, the facility failed to ensure voiced grievances and complaints against the facility were acted upon, investigated or resolved for 1 of 1 resident (R1) reviewed who had grievances. care concerns Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had anxiety was cognitively intact with no behaviors. In addition the MDS indicated R1 had a surgical wound with no pressure ulcers, was independent with activities of daily living and was incontinent of bowel and bladder and had frequent pain. R1's Care Plan dated 5/16/25, indicated R1 had limited mobility, risk for falls and had pain. R1's Care Plan also indicated alteration in behavior as evidence by diagnosis of mood disorder and anxiety staff were directed to monitor for medication effectiveness, be alert to mood and behavior changes and use kind firm approach in addition to psych visits. In addition the Care Plan indicated R1 made many demands on staff, ex: remove your shoes before entering…

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 comprehensively assess and monitor a resident's g-tube site and provide interventions for skin irritations for 1 of 1 resident (R1) reviewed for non-pressure related skin concerns. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. She required substantial/moderate assistance for roll left/right, sit to lying, and lying to sitting, dependent upon staff for all transfers, toileting and personal hygiene, bathing, and lower body dressing, and used a manual wheelchair for mobility. She had a feeding tube. Active diagnoses included: stroke, aphasia (a language disorder that affects the ability to speak, read, write, and understand what others are saying caused by a stroke, brain injury, or progressive neurological disorders), hemiplegia/hemiparesis (weakness on one side), malnutrition, diabetes mellitus (DM), hypertension (HTN), and respiratory failure. At risk for pressure ulcers and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure licensed nurses demonstrated and/or acknowledged required competency skills for completion of weekly skin assessments for 1 of 3 residents (R1) identified to have worsening skin conditions. This had the potential to affect all 83 residents who resided in the facility. Findings include: R1's Braden Scale (a tool designed to assess a patient's risk for developing pressure ulcers) dated [DATE] at 10:45 a.m. identified R1's score was 12 and indicated high risk (at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. She required substantial/moderate assistance for roll left/right, sit to lying, and lying to sitting, dependent upon staff for all transfers, toileting and personal hygiene, bathing, and lower body dressing, and used a manual wheelchair for mobility. She was frequently incontinent of bladder and always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure appropriate personal protective equipment (PPE) practices were performed during a high contact care activity for 1 of 2 residents (R3) in enhanced barrier precautions (EBP) with an indwelling device. Findings include: R3's annual Minimum Data Set, dated [DATE], identified intact cognition without behaviors. He had a functional limitation of range of motion in lower bilaterally and used an electric wheelchair for mobility. He was dependent upon nursing staff for all personal cares, transfers and toileting and personal hygiene. He had an indwelling urinary catheter and frequently incontinent of bowel. He had medical diagnoses of diabetes mellitus (DM), cerebral palsy, neurogenic bladder, paraplegia (paralysis of the lower extremities), arthritis and on anticoagulants (blood thinners). R3's care plan dated 3/6/25, identified he was on enhanced barrier precautions (EBP) related to indwelling urinary catheter with a history of urinary…

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 a system to secure stored narcotics for 1 of 9 residents (R35) reviewed for diversion. Further, the facility failed to ensure medications were properly labeled with name and directions for use and stored in a manner that addressed infection control concerns in 6 of 6 medication cart reviewed for medication storage. This had the potential to affect all 20 residents who used insulin. Findings include: During medication storage review on 2/10/25 and 2/11/25, several discontinued medications were noted to be in locked storage. Facility system was to count these medications. However, this process did not assure against diverted medications. R35's admission MDS, dated [DATE], indicated R35 was cognitively intact, and diagnoses included fracture of right lower leg, osteoporosis, and heart failure. R35's MAR dated 1/1/25 to 1/31/25, indicated a physician order start date 12/31/24 for oxycodone 2.5 mg po every 24 hours PRN for pain,…

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

Based on observation and document review, the facility failed to ensure the required nurse staffing information was posted daily for 3 of 6 days reviewed. This had the potential to affect all 57 residents residing in the facility and their visitors who may wish to view the information. Findings include: During observation on 2/3/25 at 2:29 p.m., the nurse staffing information was found on the outside of a nursing supply door, located in a side hallway of the facility. However, the posted nurse staffing information was dated 2/2/25. During observation on 2/5/25 at 7:17 a.m., posted nurse staffing information was dated 2/4/25. During observation on 2/11/25 at 9:52 a.m., posted nurse staffing information was dated 2/10/25. The facility's Nursing Hours Posting policy, revised 10/2/22, indicated the facility posted nursing staffing data daily, at the beginning of each shift, and the data was readily accessible to residents and visitors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed ensure a resident was allowed to dress in a manner of her choosing for 1 of 1 residents (R59) reviewed for dignity. Findings Include: R59's quarterly Minimum Data Set (MDS) dated [DATE], indicated R59 was severely cognitively impaired and required moderate assistance with dressing her upper body and was dependent with dressing her lower body. R59 had a diagnosis of hemiplegia (inability to move one side of her body) following a cerebral infarction (stroke) on her right dominate side. On 2/3/25 at 5:40 p.m., R59 was observed next to the nurse's station in a wheelchair with legs elevated and covered with a blanket, dressed in a hospital gown. R59's hair was brushed. On 2/4/25 at 3:17 p.m., R59 was observed sitting in a wheelchair next to the nurse's station with her legs elevated and covered with a blanket, dressed in a green hospital gown. R59 had a food tray with a lettuce salad on a tray in front of her and was holding a salmon-colored…

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 properly assess 1 of 1 residents (R39) who wished to self-administer medications. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], included R39 was cognitively intact. R39 had diagnosis of congestive heart failure (CHF) and diabetes. R39 received high risk medications including anticoagulants (blood thinner) and diuretics (increases urine production). R39's care plan with review date 1/15/25, failed to include R39's ability to self-administer medications. R39's Self Administration of medication evaluation dated 1/27/21, indicated R39 was unsafe to administer medications independently. On 2/3/25 at 2:44 p.m., medications were observed on R39's dresser. One medication cup contained 4 grey and yellow capsules. A second medication cup contained two white oblong pills. During interview on 2/3/25 at 2:44 p.m., R39 identified the grey and yellow capsules as Tamiflu. He stated he had a reaction to the medication and was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately report an allegation of sexual abuse to the state agency and law enforcement for 1 of 2 residents (R57) reviewed for abuse. In addition, the facility failed to immediately protect R57 from further abuse. Findings include: R57's annual Minimum Data Set (MDS) dated [DATE], identified cognitively intact, did not have issues with mood and did not have any behavior concerns. R57 was dependent on staff or required maximal assistance for most activities of daily living (ADL's) and did not walk. R57's diagnoses included heart failure and depression. R57's plan of care, with a last review date of 01/23/25, indicated R57 was categorically a vulnerable adult while residing in a skilled nursing facility. Staff were to be aware of statements or signs/symptoms of abuse, and if present update primary care provider, director of nursing (DON), and administrator immediately. Progress noted dated 12/29/24 at 05:36 a.m., indicated family member (FM)-A reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 1 residents (R57) who reported an alleged sexual assault. Findings include: R57's annual Minimum Data Set (MDS) dated [DATE], identified she was cognitively intact, did not have issues with mood and did not have any behavior concerns. R57 was dependent on staff or required maximal assistance for most activities of daily living (ADL's) and did not walk. R57's diagnoses included heart failure and depression. R57's plan of care, with a last review date of 01/23/25, indicated R57 was categorically a vulnerable adult while residing in a skilled nursing facility. Staff were to be aware of statements or signs/symptoms of abuse, and if present update primary care provider, director of nursing (DON), and administrator immediately. Additionally, under a focus area of history of refusing activities of daily living (ADL's), the care plan indicated cares in pairs at all times with an initiation date 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 develop and implement a comprehensive person-centered care plan that addressed resident dialysis care for 1 of 1 residents (R72). Further, the facility failed to address clothing preference and passive range of motion (PROM) for 1 of 1 resident's (R59) reviewed for care plan. Findings include: R72's dialysis patient summary report dated 12/12/24, included both AV fistula on left forearm with placement date of 10/2/24 and central venous catheter listed under active dialysis accesses. R72's quarterly Minimum Data Set (MDS) dated [DATE], included R72 was cognitively intact. R72 had diagnoses included end stage renal disease and heart failure. R72's care plan with review date 1/2/25, included R72 was at risk for complications of end-stage renal disease and received dialysis at Davita Dialysis in [NAME] three times a week. Interventions included to monitor for signs of bleeding central dialysis catheter port site. However, the care plan failed to mention…

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 medications were administered according to provider order and within professional standards for 1 of 1 residents (R2) observed during medication passes with parameters. Findings include: R2 quarterly Minimum Data Set (MDS) dated [DATE], included R2 was severely impaired cognitively. R2 had diagnoses of coronary artery disease (common form of heart disease where blood flow to the heart is limited), hypertension (high blood pressure) and dementia. R2's order summary report dated 2/10/25, included an order for metoprolol tartrate (a medication that affects the flow of blood to the arteries and veins) Tablet 25 MG Give 12.5 mg by mouth two times a day for hypertension with parameters to hold for apical pulse less than 60 beats per minute. During observation on 2/5/25 at 7:25 a.m., licensed practical nurse (LPN)-C obtained R2's blood pressure and pulse with an automatic blood pressure cuff after setting up medication in medication cup.…

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 ensure a resident received range of motion exercises for 1 of 1 residents (R59) reviewed for passive range of motion. Findings Include: R59's quarterly Minimum Data Set (MDS) dated [DATE], indicated R59 was severely cognitively impaired, required moderate assistance with dressing upper body and was dependent with dressing lower body. R59 had functional limitations in range of motion to her upper and lower extremity on one side. R59 had a diagnosis of hemiplegia (inability to move one side of her body) following a cerebral infarction (CVA) (stroke) on her right dominate side. On 2/3/25 at 5:40 p.m., R59 was observed next to the nurse's station in a wheelchair with legs elevated and covered with a blanket, dressed in a hospital gown. R59's occupational therapy Discharge summary dated [DATE], included a range of motion plan for passive range of motion (PROM) to right upper extremity (RUE) all joints and all planes of motion. R59'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 to provide assessment and monitoring for 1 of 1 residents (R72) reviewed for dialysis. Findings include: R72's quarterly Minimum Data Set (MDS) dated [DATE], included R72 was cognitively intact. R72 diagnoses included end stage renal disease and heart failure. R72's care plan with review date 1/2/25, included to monitor for signs of bleeding central dialysis catheter port site. Care plan failed to mention R72 received dialysis through fistula on left arm. R72's dialysis patient summary report dated 12/12/24, included both AV fistula on left forearm with placement date of 10/2/24 and central venous catheter listed under active dialysis accesses. During observation and interview on 2/5/25 at 2:00 p.m., R72 was noted to have a pressure dressing over fistula access site on left arm. R72 stated he had been receiving dialysis from the fistula on his left arm for a while. He last received dialysis the previous day. At time of interview, R72's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure they were free of medication error rate of five percent or greater. The facility had a mediation error rate of 8% with 2 errors out of 25 opportunities for errors involving 2 of 6 residents (R2, R240) observed during medication passes. Findings include: R2 quarterly Minimum Data Set (MDS) dated [DATE], included R2 was severely impaired cognitively. R2 had diagnoses of coronary artery disease (common form of heart disease where blood flow to the heart is limited), hypertension (high blood pressure) and dementia. R2's order summary report dated 2/10/25, included an order for metoprolol tartrate (a medication that affects the flow of blood to the arteries and veins) Tablet 25 MG Give 12.5 mg by mouth two times a day for hypertension with parameters to hold for apical pulse less than 60 beats per minute. During observation on 2/5/25 at 7:25 a.m., licensed practical nurse (LPN)-C obtained R2's blood pressure and pulse with an automatic…

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

Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 6 medication carts and one instance of medications left unattended in a resident room. Findings include: On 2/3/25 at 2:05 p.m., a medication cart on the long term care (LTC) unit of the facility was observed being unlocked and unattended. No staff was within direct eye site. At 2:09 p.m., a staff person was observed walking past the medication cart without locking it. At 2:13 p.m., care coordinator (CC)-C was observed locking the medication cart. During interview on 2/3/25 at 2:13 p.m., CC-C confirmed she locked the mediation cart after observing it unlocked and unattended. She stated the nurse was at the nurse's station and out of eye site. During observation of medication pass on 2/4/25 at 8:49 a.m., registered nurse (RN)-D brought R9's morning medications to his room. RN-D left medications in the room on a countertop next to R9's TV to return to the medication cart to collect some alcohol wipes. R9's door 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 record review, the facility failed to conduct appropriate hand hygiene during tracheostomy cares for 1 of 1 resident (R8) observed for tracheostomy cares. Further, the facility failed to ensure proper catheter drainage bag care and catheter drainage bag laying on the floor for 1 of 1 resident (R12) observed for cares. Findings include: R8's admission Minimum Data Set (MDS) dated [DATE], indicated R8 was severely cognitively impaired, dependent for all cares and transfers, required the use of oxygen, suctioning, and tracheostomy care, and had the following diagnoses: non-traumatic brain dysfunction, heart failure (heart beats ineffectively), renal insufficiency (failure of the kidneys to pump efficiently), asthma, and respiratory failure. On 2/5/25 at 7:44 a.m., tracheostomy cares were observed for R8. Licensed practical nurse (LPN)-B began to remove the soiled gauze pad from between the resident's skin and tracheostomy tube, and used a Q-Tip with gauze to clean around the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure professional standards of practice for medication administration were followed for 1 of 3 residents (R1) reviewed. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of acute embolism and thrombosis of deep vein of left lower extremity and was cognitively intact. R1's Order Recap Report dated 12/12/24, indicated R1 had an order for Buprenorphine HCL (an opioid medication used to treat acute pain, and chronic pain) Buccal (Buccal administration involves placing a drug between your gums and cheek, where it also dissolves and is absorbed into your blood) Film 600 micograms (mcg) place and dissolve one film buccally every morning and at bedtime for pain ordered on 10/14/24, and discontinued on 11/6/24. Further, R1 had an order for Buprenorphine HCL sublingual two milligrams (mg) give one mg sublingually in the morning for pain ordered on 11/6/24, and discontinued on 11/21/24. R1's Medication Error…

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 referral was made to an outside agency for psychiatric services as ordered by a physician for 1 of 1 resident (R3) reviewed. Findings include: R3's quarterly Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses of bipolar disorder, protein-calorie malnutrition, and adult failure to thrive. R1's physician order dated 11/29/24, indicated ACP (Associated Clinic of Psychology) referral, diagnosis concern for restrictive/avoidant eating. On 12/12/24 at 12:20 p.m., licensed practical nurse (LPN)-A confirmed R3 was not currently being seen by ACP and was last seen on 9/25/24. LPN-A was unaware if a referral had been made following the new order and stated social services (SS) submitted the ACP referrals. On 12/12/24 at 3:09 p.m., SS-A confirmed he was not aware of R3's order for an ACP referral and typically would be notified by the admissions staff or health coordinators would bring the order to SS-A to complete the referral. SS-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 notify resident's family of changes in condition for one of one resident (R2) reviewed. R2 had a left toe ulcer that developed on [DATE] and R1's power of attorney was not notified until R1 had to have the toe amputated on [DATE]. Findings include: R2's Facesheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R1's additional diagnoses included protein-calorie malnutrition, anorexia, type two diabetes mellitus with diabetic nephropathy and retinopathy without macular edema, vascular dementia, and human immunodeficiency virus. R2's power of attorney (POA) paperwork dated [DATE] indicated R2 appointed family member (FM)-A and FM-B to be R2's representatives. The POA paperwork indicated the paperwork wound not have expired. R2's treatment administration record (TAR) dated [DATE] indicated nurses were to complete skin prep to left great…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement policies and procedures for the use of methadone hydrochloride (HCI, a synthetic medication used to treat addiction) treatment for acquisition, administration, destruction, and an appropriate taper for 1 of 1 resident (R2) reviewed for medication administration. Additionally, the facility failed to implement policies and procedures to ensure rapid detection of potential narcotic diversion for 6 of 6 medication carts reviewed. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, and used opioids (medication used for pain relief). R2's care plan indicated a history of substance use with sobriety since 8/23, and R2 went to a methadone clinic for methadone treatment dated 11/6/23. R2's Medication Administration Record (MAR) dated May 2024, indicated R2 missed doses of methadone on 5/7/24, 5/22/24, 5/23/24, and 5/24/24. R2's progress note dated 5/7/24 at 12:43 p.m., indicated R2's methadone…

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 appropriate personal protective equipment per Centers for Disease Control and Prevention (CDC) to prevent and/or minimize spread of COVID-19 for 2 of 2 residents (R5, R15) observed for COVID-19 transmission based precaution (TBP). This deficient practice had the potential to affect all 82 residents who were currently residing in the facility. Findings Include: CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/23, identified health care personal (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). R5's quarterly Minimum Data Set, dated [DATE], identified R5 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 observation, interview, and document review, the facility failed to assess residents for the ability to self administer medications (SAM) for 2 of 2 residents (R42, R79) with medications noted at bedside. R42's admission MDS dated [DATE], identified intact cognition and diagnoses of type two diabetes with kidney complications, depression, and cataracts, glaucoma, or macular degeneration. R42 required partial to moderate assistance with eating. R42's care plan dated 12/18/23, lacked a focus area for SAM. R42's order summary and assessments dated 1/8/24, lacked direction related to SAM. During an observation and interview on 1/8/24 at 3:45 p.m., R42 was in bed. There was a half-full 8 ounce bottle of Pepto-Bismol on his bedside table, without a pharmacy label. R42 stated he could take the Pepto-Bismol any time he wanted to, and usually took a swig a few times per day for nausea. During an observation on 1/8/24 at 4:07 p.m., nursing assistant (NA)-D and NA-E entered R42's room to assist with cares. At 4:15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a clean and comfortable environment as well as failed to ensure a tube feeding pole and tracheostomy supplies cart was cleaned and in sanitary condition for 1 of 1 residents (R54) reviewed for homelike environment. Findings include: R54's annual Minimum Data Set (MDS) dated [DATE], indicated R54 was in a persistent vegetative state, had impairment on both sides of his upper and lower extremities, and was dependent on staff for all activities of daily living (ADLs). Additionally, MDS indicated R54 received 51% or more of his total calories and average fluid intake through tube feeding. R54's diagnoses included brain damage from lack of oxygen, aphasia (language disorder affecting the ability to communicate), gastrostomy (a surgically inserted tube through his abdomen into the stomach for nutrition), and tracheostomy (a surgically inserted hole into his windpipe that provided an alternative airway for breathing). R54's treatment…

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 revise the comprehensive care plan for 1 of 5 residents (R23), reviewed for activities of daily living (ADL). In addition, the facility failed to ensure residents/resident representatives were allowed to participate in care planning for 2 of 5 (R23, R67 ) reviewed for ADLs. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnoses which included: schizophrenia, chronic obstructive pulmonary disease (COPD) and respiratory failure. R23's MDS also identified R23 required supervision or touching assistance for upper and lower body dressing and set up assistance for personal hygiene. R23's Care Area Assessment (CAA) dated 12/6/23, identified R23 had some cognition issues, planned to return to her apartment where R23 lived alone. R23's CAA also identified R23 received physical therapy (PT) and occupational therapy (OT) per doctor of medicine (MD) order and was at risk…

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 the services to maintain dressing and personal hygiene needs for 1 of 5 residents (R23) observed for activities of daily living (ADL's). Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnoses which included: schizophrenia, chronic obstructive pulmonary disease (COPD) and respiratory failure. R23's MDS also identified R23 required supervision or touching assistance for upper and lower body dressing and set up assistance for personal hygiene. R23's Care Area Assessment (CAA) dated 12/6/23, identified R23 had some cognition issues, planned to return to her apartment where R23 lived alone. R23's CAA also identified R23 received physical therapy (PT) and occupational therapy (OT) per doctor of medicine (MD) order and was at risk for further decline in ADLs, isolation, complications of immobility and incontinent. R23's functional abilities, self-care 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 provide fingernail care to a dependent resident for 1 of 1 resident (R54) reviewed for dependent activities of daily living (ADL) care. Findings include: R54's annual Minimum Data Set (MDS) dated [DATE], indicated R54 was in a persistent vegetative state and was dependent on staff for hygiene and grooming. R54's diagnoses included brain damage from lack of oxygen, contractures (fixed, tightening of muscles, tendons, and/or ligaments that prevent movement), and aphasia (language disorder affecting the ability to communicate). R54's Care Area Assessment (CAA) dated 12/25/23, triggered for alteration in skin integrity related to brain damage, immobility, and contractures. R54's Braden Scale assessment dated [DATE], indicated R54 was at a high risk for developing pressure injuries in part, due to his very limited response to pain and his inability to communicate discomfort. R54's physician orders included the application of splints 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 pain management was provided in accordance with professional standards of practice for 1 of 1 resident (R21) reviewed for pain during wound care. Finding include: The undated, National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages document defines a stage 2 pressure injury (pressure ulcer) as partial-thickness skin loss with exposed dermis (middle layer of skin). Fat was not visible and deeper tissues were not visible. Granulation tissue (new tissue and blood vessels that form on a healing wound), slough and eschar (dead tissue) were not present. A stage 4 pressure injury was defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound ' s edge) and/or…

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 post-dialysis access site monitoring was completed and documented for 1 of 1 resident (R41) reviewed for dialysis. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was cognitively intact impairment and had diagnoses of end stage kidney failure, heart disease, and required dialysis (treatment to filter blood when kidneys are no longer able). R41's Care Area Assessment (CAA) dated 10/25/23, lacked documentation of R41's fistula (dialysis intravenous access site) and required monitoring of thrill and bruit (an auditory method of checking fistula patency). R41's provider orders dated 6/9/23, instructed staff to monitor vital signs before and after dialysis treatments on Mondays, Wednesdays, and Fridays. No further orders located in treatment administration record (TAR) to assess dialysis access site. R41's nursing progress notes from 12/9/23 through 1/8/24, reviewed and lacked documentation of assessment 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 provide medically related social services for 1 of 1 resident (R23) who lacked sufficient clothing. Findings Include: R23's admission Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnoses which included: schizophrenia, chronic obstructive pulmonary disease (COPD) and respiratory failure. R23's MDS also identified R23 required supervision or touching assistance for upper and lower body dressing and set up assistance for personal hygiene. R23's Care Area Assessment (CAA) dated 12/6/23, identified R23 had some cognition issues, planned to return to her apartment where R23 lived alone, and was at risk for isolation, depression, and further cognitive decline. R23's care plan dated 11/29/23, identified R23 was admitted to the facility 11/22/23, and had alteration in psychosocial well-being related to schizophrenia diagnosis. R23's interventions included monitor and respond to unmet needs, contact family with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to have a method or system to ensure the facility offered or provided updated pneumococcal vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations for 1 of 5 residents (R49) reviewed for immunizations. This had the ability to affect all 82 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide: a) the pneumococcal conjugate vaccines (PCV)-20 at least 1 year after prior PCV-13, b) the pneumococcal polysaccharide vaccine (PPSV)-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turned [AGE] years old. 2) Adults [AGE] years of age or older,…

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 complaints of worsening right arm pain following a fall was comprehensively assessed and treated in a timely manner to provide comfort for 1 of 3 residents (R1) reviewed for falls. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, and had a diagnosis of heart failure. R1's Physician Orders dated 10/30/23 directed acetaminophen (Tylenol, a pain reliever) 1000 milligrams (mg) three times a day. R1 did not have an order to receive acetaminophen on a PRN (as needed) basis. R1's medication administration record (MAR) for 11/23 indicated she received acetaminophen four scheduled times following the fall. R1 rated her pain as on 11/7/23 as 5 out of 10 (0 being no pain to 10 being the worst pain) for the morning dose, 6 out of 10 mid-day dose, 7 out of 10 evening dose. On 11/8/23 R1 rated her pain as 7 out of 10 for the morning dose. R1's medical record lacked indication if the scheduled acetaminophen 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.