North Ridge Health And Rehab

Based on observation, interview and document review, the facility failed to ensure routine personal hygiene and grooming (i.e., shaving) was provided to 1 of 1 residents (R12) reviewed for Activities of Daily Living (ADLs) who were dependent on staff for their care.Findings include:R12's admission Minimum Data Set (MDS) assessment, dated 3/6/26, indicated R12 was cognitively intact, required partial to moderate assistance with personal hygiene, and had not refused or rejected cares.R12's care plan, reviewed 6/24/26, indicated R12 required the assistance of one staff for personal hygiene.During an observation and interview on 6/22/26 at 2:04 p.m., R12 had scruffy facial hair, approximately 3/4 of an inch long, covering his face and neck. R12 stated he preferred to be clean shaven. An electric razor was plugged into the wall on the floor next to R12's bed.During an observation on 6/23/26 at 10:27 a.m., R12 continued to have scruffy facial hair covering his face and neck.During an observation on 6/23/26 at 3:15 p.m., R12 had scruffy facial and neck hair present, and the electric shaver…

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 fall interventions were implemented to prevent further falls and potential injury for 1 of 3 residents (R6) reviewed for falls. Additionally, the facility failed to comprehensively assess to prevent potential injury for 1 of 1 residents (R44) reviewed for smoking. Findings include: R6's annual Minimum Data Set (MDS), dated [DATE], indicated R6 was cognitively intact, had not rejected cares, was independent with activities of daily living (ADLs), and diagnoses included arthritis and depression. R6's progress note, dated 5/14/26 at 5:13 a.m., indicated that R6 slid from bed and was found on the floor with no injuries observed. R6's fall risk management, dated 5/14/26, indicated R6 had fallen out of bed and was found on her bedside floor by staff. The report indicated R6 stated she was rolling in her bed when she had fallen. The report indicated R6 thought the bed was too small, causing her to fall off her bed, and R6 was given a new…

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 provider orders were obtained to maintain an indwelling urinary catheter for 1 of 1 residents (R246) reviewed for catheter care.Findings include: R246's admission Minimum Data Set (MDS), dated [DATE] indicated R246 had moderate cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included diabetes, atrial fibrillation, hypertension, dementia, and myelodysplastic syndrome (type of cancer in which the bone marrow does not make enough healthy blood cells). R246's Order Summary identified an order dated 6/4/26, for an indwelling (foley) caterer for comfort. However, the order failed to indicate the catheter size and balloon size needed for catheter replacement. R246's treatment administration record (TAR), dated 6/1/26 to 6/30/26 indicated an order for an indwelling (foley) catheter for comfort. However, the orders failed to include catheter size and balloon size needed for…

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

Based on interview and document review, the facility failed to ensure timely and effective interventions were implemented for significant, unplanned weight loss and failed to ensure consistency between physician orders and care plan directives related to weight monitoring for 1 of 1 residents (R256) reviewed for weight loss. Findings include:R256's annual Minimum Data Set (MDS) assessment, dated 5/25/26, indicated R256 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs), including feeding, and had a diagnosis of weight loss. R256 received a mechanically altered diet and was not on a prescribed weight-loss regimen.R256's physician order, dated 5/1/23, indicated an order for monthly weights. Additional orders included a house supplement shake 4 oz twice daily, initiated 1/9/24, for nutritional supplementation and ProStat Advanced Wound Care Liquid daily, initiated, 6/27/25 for wound healing.R256's weight records indicated R256 weighed 153.2 pounds (lbs) on 4/3/26 and 127 lbs on 6/3/26. These weights indicated a weight loss of 26.2 lbs…

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 respiratory care and services were provided according to professional standards of practice and physician orders when the facility failed to ensure tracheostomy orders, included the specific type and size of tracheostomy tube, for 2 of 2 residents (R147 and R152) reviewed for tracheostomy care. In addition, the facility failed to obtain physician orders for oxygen therapy, including prescribed flow rate and administration parameters, for 1 of 3 residents (R152) reviewed for oxygen therapy, and the facility failed to ensure oxygen was administered according to physician orders for 1 of 3 residents (R14) reviewed for oxygen therapy.Findings included:R14R14's quarterly Minimum Data Set (MDS), dated [DATE], identified R14 had intact cognition and required staff assistance with activities of daily living (ADLs). R14's diagnoses included respiratory failure, tracheostomy status (a surgically created opening in the neck to assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure non-pharmacological pain interventions were offered, implemented, and documented when administering as-needed pain medication for 1 of 1 resident (R142) reviewed for pain management.Findings include: R142's diagnoses list, dated 6/12/26, included malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain. R142's Pain Assessment Instrument (PAINAD), dated 6/14/26, documented R142 had no pain. R142's pain assessment, dated 6/16/26, indicated R142 was cognitively intact and had experienced frequent pain during the previous five days. R142's physician orders, dated 6/12/26, included the following as needed (PRN) medications for pain: hydromorphone 8 milligrams (mg) every 2 hours PRN for pain, ibuprofen 600mg every 8 hours PRN for pain, methocarbamol [PHONE NUMBER]mg every 6 hours PRN for muscle spasms, and baclofen 2.5mg two times daily PRN for muscle 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, interview and document review, the facility failed to ensure licensed nursing staff demonstrated competency by administering the incorrect dose of a controlled medication and inaccurately documenting controlled substance administration for 1 of 3 residents (R142) reviewed for medication administration. Findings include:R142's diagnoses list, dated 6/12/26, included malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain.R142's physician orders, dated 6/12/26, included an order for Methadone HCl 10 milligram (mg) tablets - 50 milligrams (mg) every morning, 20 mg daily (midday), and 40 mg at bedtime for pain. During observation on 6/24/26 at 8:15 a.m., Licensed Practical Nurse (LPN)-D entered R142's room to administer scheduled medications. During the medication pass, R142 requested as-needed pain medication and LPN-D why there were only two pain pills in his medication cup as he should have five pills. LPN-D told R142 that the medication cup contained his morning dose.Review of R142's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure recommendations from the consulting pharmacist were acted upon timely to reduce the risk of adverse effects for 1 of 5 residents (R9) reviewed for unnecessary medication use.Findings include: R9's admission Minimum Data Set (MDS), dated [DATE], indicated R9 had severe cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included edema, dementia, hypertension, insomnia and encephalopathy (broad term for any disease, damage, or malfunction that affects the brain). R9's Pharmacy Consultation Report, dated 5/19/26, indicated the facility needed to obtain a psychotropic consent for a new order of trazadone (a psychotropic medication) for insomnia. Additionally, the report indicated the facility needed to monitor R9's sleep while R9 received trazadone. However, R9's medical record lacked evidence that the facility obtained psychotropic consent for R9's trazodone. Additionally, R9's medical record lacked…

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 adequate monitoring was completed for 1 of 5 residents (R255) reviewed for unnecessary medications.Findings include: R255's admission Minimum Data Set (MDS), dated [DATE], indicated R255 had severe cognitive impairment, required substantial assistance with activities of daily living (ADLs), and diagnoses included hypertension, chronic kidney disease, dementia, diabetes, and anxiety. R255's order summary report, printed 6/25/26, included an order dated 5/12/26 for metoprolol succinate extended release 50 milligrams (mg) by mouth one time daily, hold for systolic blood pressure (SBP) less than 100 or heart rate (HR) less than 60. R255's medication administration records (MAR) for May 2026 and June 2026, indicated R255's blood pressure was monitored. However, R255's MARs failed to indicate R255's heart rate was monitored and recorded as per provider order. During an interview on 6/25/26 at 10:56 a.m., registered nurse (RN)-I stated 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 coordinate blood draws as ordered by the provider for 1 of 2 residents (R25) reviewed for dialysis.Findings include:R25's admission Minimum Data Set (MDS) assessment, completed on 5/12/26, indicated R25 was cognitively intact, was able to communicate wishes to others, understood others, and diagnoses included renal insufficiency with dependence on dialysis and anemia.R25's progress note on 6/8/26, at 1:56 p.m., indicated a call was received from the lab to alert facility R25 had a critical lab value of hemoglobin (hgb-the oxygen carrying cells in the blood) was low at 6.9 (normal hemoglobin level is 12 - 16). The note indicated that the provider was updated. The progress notes lacked indication of subsequent blood draws following the last blood draw on 6/15/26.During interview on 6/22/26 at 1:19 p.m., R25 stated he felt good and denied any symptoms of nausea or vomiting, although stated he was tired after dialysis. R25 stated he had his Hgb checked while at dialysis and his most recent lab value was at 8.2.…

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 oral health needs were met for 1 of 1 residents (R2) reviewed for denture fit and function resulting in the resident not consistently receiving or using dentures despite documented issues with improper fit and the resident's expressed desire to use them. Additionally, the facility failed to ensure routine dental service recommendations were followed to promote oral hygiene and reduce the risk of complications for 1 of 1 residents (R21) reviewed for dental services.Findings include:R2's quarterly Minimum Data Set (MDS) assessment, dated 4/6/26 indicated R2 was cognitively intact and required partial to moderate assistance with most activities of daily living (ADLs). R2's dental note, dated 10/1/24, documented R2's dentures did not fit properly and required adjustment, with the provider noting additional adjustments may be needed as the resident continued to adapt to new dentures. R2's MDS oral/dental assessment, dated 12/22/25,…

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

Based on observation, interview, and document review, the facility failed to implement infection prevention and control practices by ensuring staff performed hand hygiene and changed gloves between contaminated and clean resident care tasks during incontinent care for 1 of 1 residents (R142) reviewed for incontinence care.Findings include:R142's admission Minimum Data Set (MDS) assessment was in progress following admission to the facility on 6/12/26.R142's diagnoses, dated 6/12/26, included malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain.R142's pain assessment, dated 6/16/26, indicated R142 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had experienced frequent pain during the previous five days.R142's care plan, dated 6/12/26, indicated the resident had a self-care deficit related to a diagnosis of cancer and required moderate assistance with most activities of daily living (ADLs). During observation on 6/24/26 at 8:32 a.m., Nursing Assistant (NA)-F provided…

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 use the correct brand sling for Hoyer (full-body mechanical lift) in accordance with manufacturer's instructions for (R1) who had a fall from a lift and failed to ensure comprehensive assessments for Hoyer sling sizes completed according to manufactures recommendations and failed to ensure the sling size was represented on the care plan for 2 of 2 residents (R1, R2) who required Hoyer lifts for transfers. In addition, the facility failed to ensure comprehensive harness assessments were completed to ensure safe transfers for 3 of 3 residents (R3, R4, R5) who required the sit-to-stand mechanical lift for transfers.Findings include:R1R1's annual Minimum Data Set (MDS) assessment dated [DATE], identified R1 had moderate cognitive impairment and no behaviors or rejection of care. R1 had an impairment to one side of upper and lower extremity and was dependent on staff with wheelchair mobility and transfers. The MDS identified R1 had 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 interviews and document review the facility failed to comprehensively develop and implement care plan interventions for 1 of 3 residents (R2) when R2 required in-center hemodialysis (also known as dialysis) (going to a dialysis center for therapy that filters your blood outside your body using a machine and a manufactured filter) three days a week. Findings include:R2's Medicare 5-Day Minimum Data Sheet (MDS) dated [DATE], indicated R2 admitted to the facility on [DATE] with intact cognition, diagnoses included renal (kidney) insufficiency, and required dialysis. R2's provider orders dated 1/27/26, indicated dialysis three times weekly and directed nurses to complete a post-dialysis assessment on Tuesdays, Thursdays and Saturdays. On 1/29/26, the provider orders were modified to complete the post-dialysis assessments on Mondays, Wednesdays and Fridays instead. R2's care plan reviewed 4/30/26 lacked a focus area and interventions for dialysis treatment. During an interview on 5/1/26 at 2:16 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure assessment of the resident's condition and monitoring for complications before and after dialysis, failed to ensure staff was knowledgeable about providing care, and failed to ensure the medical record reflected accurate care and monitoring of the dialysis access site for 1 of 1 resident (R2) reviewed for dialysis. Findings include:R2's Medicare 5-Day Minimum Data Sheet (MDS) dated [DATE], indicated R2 admitted to the facility on [DATE] with intact cognition, diagnoses that included renal (kidney) insufficiency, and required dialysis. R2's provider orders dated 1/27/26, indicated hemodialysis three times weekly, and nurses would complete a post-dialysis assessment on Tuesdays, Thursdays and Saturdays. On 1/29/26, the provider orders were modified to complete the post-dialysis assessments on Mondays, Wednesdays and Fridays instead.R2's care plan reviewed 4/30/26 lacked a focus area and interventions for dialysis treatment. R2's progress notes…

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 residents were free of significant medication errors for one of one resident (R2) when R2 had an order for Oxycodone 10 milligrams (mg) with instructions to separate the doses by a minimum of four hours and to separate doses from Suboxone by a minimum of two hours. The facility failed to follow these instructions 12 times between 10/10/25 and 10/27/25. The facility also failed to ensure medications were given within one hour before the scheduled administration time to one hour after the scheduled administration time. Between 10/1/25 and 10/31/25, the facility failed to ensure medications were given within one hour of the scheduled administration time to one hour after the scheduled administration time 360 times. These deficiencies had the potential to impact all resident's in the facility. R2's admission record dated 12/3/25 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of acute and subacute infective endocarditis.…

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 accurately document turning and repositioning for one of one resident (R2) reviewed when R2's care plan stated she would be turned and repositioned every two hours and the staff stated they do not document when a resident is turned and reposition nor could recall turning and repositioning R2.R2's admission record dated 12/3/25 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of acute and subacute infective endocarditis. R2's additional diagnoses included pneumonitis due to inhalation of food and vomit, displaced bicondylar fracture of left tibia, chronic obstructive pulmonary disease, dysphagia, other lack of coordination, difficulty walking, cognitive communication deficit, peripheral vascular disease, and personal history of other venous thrombosis and embolism. R2 was discharged from the facility on 11/21/25. R2's care plan dated 9/19/25 indicated R2 would be repositioned every two hours to facilitate lung secretion…

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 promote dignity for 2 of 3 residents (R3, R6) who required assistance with toileting and staff did not respond timely to requests for assistance with toileting and toileting hygiene, which resulted in incontinence or not getting changed timely.Findings include:R3R3's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, a urinary catheter (removed [DATE]), incontinence of bowel, full dependence upon staff for transfers, and an inability to walk. R3's care plan dated [DATE], indicated a risk for falls, keep the call light in reach, bowel incontinence, care in pairs, and prompt response to all requests for assistance. Additionally, the care plan dated [DATE], indicated R3 was resistive to care and would yell at staff to leave the room.R3's progress notes indicated many refusals of care including lab work and medications, and further indicated R3 was verbally abusive to staff, yelling at them, and kicking them out of the room when…

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 implement resident-directed care and treatment consistent with provider orders and professional standards for 1 of 3 residents (R2) reviewed for supplemental oxygen use.Findings include:R2's quarterly minimum data set (MDS) dated [DATE], identified moderately impaired cognition with diagnoses which include acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). R2 utilized oxygen therapy while at the facility.R2's provider order dated 12/18/24, instructed staff to apply continuous oxygen at 2 liters per minute (lpm) by nasal cannula to maintain oxygen saturations above 90% with a frequency check of every shift. Required supplementary documentation included oxygen saturations.R2's care plan dated 7/10/25, instructed staff to administer oxygen according to provider order.Review of R2's vital signs documentation from 5/8/25, through 7/10/25, revealed R2's oxygen saturation had been checked once on 5/8/25, 5/15/25, 5/22/25,…

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 respiratory care consistent with professional standards and the comprehensive person-centered care plan for 1 of 3 (R3) residents reviewed for supplemental oxygen use. Findings include:R3's quarterly minimum data set (MDS) dated [DATE], indicated intact cognition with diagnoses which included chronic kidney disease and heart failure. R3 did not use oxygen therapy at the facility.R3's provider order list dated 7/10/25, lacked an order for supplemental oxygen use and monitoring.R3's care plan lacked information regarding supplemental oxygen use.Review of R3's vital signs documentation from 5/1/25 through 7/10/25, revealed R3 utilized oxygen via nasal cannula (NC) on six days in July, at least 17 days in June (9 days there was no information documented), and 11 days in May starting on 5/16/25 (3 days there was no information documented).A nursing note dated 6/2/25, indicated R3 utilized 2 liters per minute (L) of supplemental…

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

Based on observation and interview, the facility failed to ensure a complete wireless call system in which staff were provided with functioning devices alerting them to call light activation in their possession. This had the potential to affect all 250 residents at the facility. Findings include: During an observation on 3/5/25 at 2:35 p.m., it was noted there were no call light indicators above the resident rooms on the East side in hallways 500, 600, or 700. At about the middle of each hall there were two scrolling kiosks of about two feet in length and five inches tall, suspended from the ceiling in facing opposite ways. The kiosk displayed the resident room and bed number of the resident who had activated their call light. During an interview on 3/5/25 at 2:45 p.m., nursing assistant (NA)-E stated she knew when a resident call light went off by the kiosk in the hallway. NA-E stated the NAs didn't carry a pager or anything that alerted her a call light had gone off. NA-E also stated they didn't carry any type of communication, if they were in a room with a resident and needed…

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 emergency kits were tracked to prevent potential theft and diversion of medications. This had the potential to affect all residents residing on the nursing unit. Findings include: During a tour on 3/5/25 at 11:48 a.m., with registered nurse (RN)-E of the medication room for the 500 wing the refrigerator had an insulin kit with lorazepam (a benzodiazepine [controlled substance] medication used to treat anxiety) one bottle 2 milligrams per milliliter (mg/ml). RN-E verified the kit was not part of the narcotic count at the change of shift and the box was not secured in the refrigerator. On 3/7/25 at 8:41 a.m., the director of nursing (DON) stated the emergency kit with insulin and lorazepam did not need to be counted at the shift change because the kit was secured with a green tab that only pharmacy could replace. The DON did however, state when the narcotic count was done staff should have been laying eyes on the box because it wasn't secured in the refrigerator. The facility policy Controlled…

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 they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 22.58 % with 7 errors out of 31 opportunities for error involving 4 of 9 residents (R309, R193, R183, R38) who were observed during the medication passes. Findings include: R309's admission Record dated 3/7/25, identified R309 had diagnoses which included rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs) , and protein-calorie malnutrition. R309's Active Orders as of 3/7/25, identified R309 had an order for calcium carbonate-vitamin D with minerals - give one tablet by mouth two times a day. On 3/3/25 at 5:10 p.m., licensed practical nurse (LPN)-C brought R309 calcium carbonate 500 plus D, LPN-C verified the expiration date on the bottle was 12/2024, and that the medication was expired. R193's admission Record dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure insulin pens were dated when opened and dated with an expiration date for 13 residents (R4, R92, R166, R105, R114, R202, R85, R101, R196, R189, R206, R720, R462) and outdated medications were removed and disposed of properly in 8 of 10 medication carts. In addition, the facility failed to ensure supplies were not outdated, discharged resident medications were properly disposed of for (R721, R722), and medication temperatures were within safe temperature ranges for 8 residents (R2, R29, R71, R30, R91, R92, R109, R149), in 4 of 5 medication rooms. This deficient practice had the potential to affect residents receiving medications from these medication carts and medication rooms. Findings include: During a tour on [DATE] at 2:06 p.m., with registered nurse (RN)-G at the 3 North medication cart, an aspart insulin pen (rapid-acting insulin used to treat type 1 and type 2 diabetes) for R4 with an open date of [DATE], and no expiration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) and/or standard precautions were followed to reduce the risk of infection to others for 2 of 3 residents (R611, R612) reviewed for EBP during tracheal care. In addition, the facility failed to ensure infection control practices were followed regarding tracheal suctioning for 1 of 3 (R612) reviewed for tracheal care. The facility also failed to ensure proper hand sanitization occured during cares for 1 of 3 residents (R97) standard precautions. Also, the facility failed to follow clean procedures when administering tube feedings for 1 of 2 residents (R90) reviewerd for tube feedings. The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control…

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 call light that accommodated the resident's needs or an acceptable alternative, was provided or implemented to promote safety and allow for means of notification for 1 of 1 residents (R190) reviewed for the accommodation of needs. Findings include: R190's admission Minimum Data Set (MDS) dated [DATE], indicated R190 had a functional limitation in the range of motion of both upper extremities and was dependent on staff for almost all his activities of daily living (ADL) needs. R190's care plan dated 5/15/24, indicated R190 had a communication problem related to his tracheostomy (surgical hole in the windpipe), and his call light was to be within reach. The care plan did not discuss what type of call light R190 needed. R190's care plan dated 9/24/24 indicated R190 utilized mittens on his right hand to prevent pulling on his catheter and tracheostomy, and R190 had left-sided weakness. R190's census report dated 3/1/25, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure family requested pretreatment of nausea occured prior to meals for 1 of 1 residents (R97) reviewed for self-determination. Findings include: R97 significant change Minimum Data Set (MDS) dated [DATE], indicated R97 was severely cognitively impaired. Section O. indicated R97 had been admitted to hospice care. R97's diagnoses included arthritis and non-Alzheimer dementia. R97's careplan last updated 2/25/25, indicated R97 had been admitted to hospice. Palliative care goals included optimize treatment and control of physical symptoms such as anorexia, nausea and vomiting. R97's Order Summary Report Active orders as of 3/6/25 included the following order: Ondansetron oral tablet disintegrating 4mg give one tablet sublingually two times a day for nausea vomiting. 1 tab under the tongue before meals and at bedtime. R97's Medication Administration Records (MAR) for February and March showed that R97's ondansetron had been scheduled to give at 4:00 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure ongoing monitoring and assessments of the resident ' s condition during restraint use were completed to decrease the likelihood of adverse outcomes of restraint use (skin breakdown, injury from attempts to free self, decline in physical functioning, etc.) and failed to complete a comprehensive assessment and/or re-assessment to determine if the least restrictive device (restraint mitt) was used or determine if the restraint was effective when 1 of 2 residents (R190) reviewed for restraint use, was found to be able to self-decannulate his tracheostomy tube while the restraint was in place. Findings include: R190's admission Minimum Data Set (MDS) dated [DATE], indicated R190 had a functional limitation in the range of motion of both upper extremities and was dependent on staff for almost all his activities of daily living (ADL) needs. The MDS indicated that physical restraints were not used on R190. R190's care plan dated 5/15/24,…

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 observation, interview and document review the facility failed to initiate and complete a Significate Change in Status Assessment (SCSA) for 1 of 1 resident (R42) after a physical and cognitive decline following a stroke. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual) indicates the SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines. A significant change is a major decline in resident status that will not normally resolve itself without intervention by staff, impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision of the care plan. R42's quarterly Minimum Data Set (MDS), dated [DATE], indicated R42 had severe cognitive impairment, significant weight loss, a mechanically altered diet, upper and lower extremity impairment on one side and 2 or more falls since readmission to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on inteview, obsersavation and document review, the facility failed to ensure a comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 1 resident (R86) reviewed for care needs (i.e. interventions and identfication of pressure ulcer/laundry/preference of care giver/communication ability/ambulation ability). R86's quarterly Minimum Data Set (MDS) assessment, dated 2/15/25, indicated R86 had severely impaired cognition with no hallucinations or delusions present, no behaviors and no rejection of care. R86 required moderate staff assistance with showering, lower body dressing, footwear, transfers from bed/chair/toilet/shower and personal hygiene. R86 required set up assistance from staff for oral hygiene and supervision for toileting hygiene. Furthermore, Section M skin conditions indicated R86 was at risk for developing pressure ulcers and indicated R86 had one stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red…

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 timely and quarterly care conferences for 3 of 4 residents (R184, R224, R146) reviewed for care planning. Findings include: R184: R184's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R184 was cognitively intact. Diagnoses included cancer, gastroesophageal reflux disease and post-traumatic stress disorder Review of R184's progress notes indicated a staff member with Anoka County requested a care conference on 11/18/24. Review of R184's care conference forms and progress notes identified care conferences were held on 1/24/25, 5/6/24 and 1/30/24. The care conference forms, and progress notes lacked a documented care conference around 11/24 as requested by Anoka County. During an interview on 3/3/25 at 6:29 p.m., R17 stated there is never an invite sent for care conferences and was not sure when the last care conference occurred. During an interview on 3/5/25 at 10:42 a.m., registered nurse (RN)-R stated care conferences were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 2 of 9 residents (R21, R28) reviewed for activities of daily living (ADLs) and who were dependent on staff for their ADLs, routinely had their fingernails cleaned and trimmed. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, diabetes mellitus and chronic kidney disease (CKD). R21's MDS identified the need for moderate assistance with bathing, dressing, and toileting. R21's provider orders dated 1/30/25, identified an order for a weekly bath on Fridays including nail care and shaving. R21's care plan dated 2/6/25, identified the need for extensive assistance with bathing but didn't specifically address nail care. During an observation on 3/4/25 at 8:56 a.m., R21's fingernails were noted to be about one-eighth of an inch long with dark matter underneath all of them. During an…

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 compressively reassess a resident for activity interest and socialization needs after hospitalization for a stroke for 1 of 2 residents (R42) reviewed for activities who was no longer able to communicate verbally with other residents and move around the facility independently. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated R42 had severe cognitive impairment, significant weight loss, lower and upper extremity impairment to one side and required substantial to maximum assistance with toileting and bathing. The MDS further indicated R42 had been admitted to the care facility on 4/1/15. R42's progress notes dated 11/1/24 - 3/7/25, indicated R42 was hospitalized on [DATE] - 1/10/25 for a stroke with right sided weakness. R42's care plan revised 7/25/24, indicated R42 preferred to be to be in room engaging in independent activities or going outside or fresh air rather than going to group programs offered. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure orders were current and accurate for 1 of 1 resident (R90) reviewed for orders. In addition, facility failed to ensure site care was performed for 1 of 2 residents (R4) reviewed for tube feeding Findings include: R90's quarterly Minimum Data Set (MDS) dated [DATE], identified R90 had diagnoses which included intestinal malabsorption (a condition that prevents absorption of nutrients through the small intestine), gastrostomy tube status (a flexible, hollow tub inserted through the abdominal wall and into the stomach), malnutrition, diabetes mellitus, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety, and depression. R90 was cognitively intact and independent with activities of daily living. R90's Order Summary Report dated 3/7/25, identified R90 had orders that included the following: Two liter fluid restriction every shift start date 11/13/24, order status active Antibiotic…

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 follow identifed pressure relieving interventions, to timely identify a wound as a pressure ulcer and failed to follow care plan interventions to promote healing and prevent worsening of a pressure ulcer for 1 of 4 residents (R4) reviewed for pressure ulcer care. Findings include: R4's re-admission Minimum Data Set (MDS) dated [DATE], indicated R4 was moderately cognitively impaired and was at risk of developing pressure ulcers but did not have any unhealed pressure ulcers at the time of admission and advised pressure reducing devices for R4's chair and bed. Hospital provider notes dated 12/30/24, identified R4 as having a stage 3 pressure ulcer [defined as full-thickness loss of skin in which adipose (fat) tissue is visible. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, and cartilage are not viewable. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury] Nursing progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a nursing functional maintenance program was implemented to prevent a possible decline in range of motion (ROM) for 1 of 6 residents (R190) reviewed for range of motion. Findings include: R190's admission Minimum Data Set (MDS) dated [DATE], indicated R190 had a functional limitation in the range of motion of both upper extremities and was dependent on staff for almost all his activities of daily living (ADL) needs. R190's care plan dated 2/25/25, indicated R190 had a functional maintenance program to prevent furthering of his contractures and to prevent skin breakdown. The care plan indicated the nursing assistants (NA)s were to complete bilateral lower extremity ankle and knee ROM with R190. R190's Functional Maintenance Program (FMP) dated 2/18/25, indicated nursing staff were to complete bilateral lower extremity ankle and knee ROM with R190 daily, and the program was signed by physical therapist (PT)-A. R190's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R90) who was observed using an electric heating pad, was free of potential injury. Findings include: R90's quarterly Minimum Data Set (MDS) dated [DATE], identified R90 had diagnoses which included intestinal malabsorption (a condition that prevents absorption of nutrients through the small intestine), gastrostomy tube status (a flexible, hollow tub inserted through the abdominal wall and into the stomach), diabetes mellitus, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety, depression, hypothyroidism, and insomnia. R90 was cognitively intact and independent with activities of daily living. R90's Order Summary Report dated 3/7/25, did not identify any orders for a heating pad or heat therapy. A review of R90's care plan dated 10/25/24, identified R90 had a potential for pressure ulcer development related to disease process. Interventions included the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure appropriate interventions were taken to reduce the risk of aspiration for 2 of 2 residents (R4, R129) reviewed who used a tube feeding and was observed to be positioned flat in bed while their feeding was running. In addition, the facility failed to ensure infection prevention practices were followed and tube feeding was administered at the ordered flow rate for 1 of 2 residents (R4) reviewed for tube feeding administration. Findings include: R4's re-admission Minimum Data Set (MDS) dated [DATE], indicated R4 was moderately cognitively impaired and received 51% or greater of their nutrition by tube feeding. R4's diagnoses included the diagnoses of epilepsy, traumatic brain injury, quadriplegia, diabetes, and sepsis. R4's care plan tube feeding focus area udpated 1/16/15, indicated R4 was receiving nutrition via tube feeding and listed Osmolite 1.5 at 50 ml [milliliters]/hour. Goals included free of aspiration, insertion site will…

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 oxygen order parameters were followed for 1 of 4 residents (R21) and that provider orders for as needed (PRN) oxygen administration were in place for 1 of 4 residents (R204) reviewed for respiratory care. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. R21's MDS also identified continuous oxygen therapy. R21's provider orders dated 1/30/25, identified an order for oxygen at 3.5 liters per minute via nasal cannula to keep oxygen saturation levels greater than or equal to 90%. Review of R21's care plan dated 1/31/25, identified altered respiratory status related to chronic respiratory failure and COPD with an intervention to provide oxygen as ordered. Review of R21's electronic medical record (EMR) identified oxygen saturation readings from 3/1/25 to 3/6/25 ranging from 92-100%. 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 in observation, interview and document review the facility failed to assess a resident for potential trauma, who was found to have vulvar lesions and under went a Sexual Assault Nurse Examiner exam, in order to implement any potential interventions to ensure R42 was safe and did not have lasting negative effects for 1 of 1 resident (R42) reviewed for trauma informed care. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated R42 had severe cognitive impairment, significant weight loss, lower and upper extremity impairment to one side and required substantial to maximum assistance with toileting and bathing. The MDS further indicated R42 had been admitted to the care facility on 4/1/15. R42's progress note dated 12/25/24, indicated R42 was found unresponsive in her room and was transferred to the hospital. R42's progress note dated 1/10/25, indicated R42 arrived back to the facility via stretcher. R42's hospital Discharge summary, dated [DATE], indicated R10 was hospitalized from…

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 pharmacy consultant recommendations were followed up on in a timely manner for 2 of 5 residents (R183, R204) reviewed for medication management. Finding included: R183's quarterly Minimum Data Set (MDS) dated [DATE], identified R183 had intact cognition. R13's diagnoses included hypertension, renal failure, diabetes mellitus, and depression. R183's consultant pharmacist's medication review reports (CPMR) included the following: - 1/29/25, identified the same recommendation as the one on 9/26/24, because no action was taken. The CPMR was not addressed and signed off until 3/6/25. - 10/22/24, indicated R183 took Aripiprazole (mental health medication) and Reglan (medication for stomach) which could cause involuntary movements of various parts of the body and lacked an Abnormal Involuntary Movement Scale (AIMS) (assessment to monitor for involuntary movements of the body) had not been documented in the previous 6 months. This CPMR was not…

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 scheduled antifungal medication without an end date was evaluated for the appropriateness of its continued use for 1 of 6 residents (R129) reviewed for unnecessary medications. Findings include: R129's quarterly Minimum Data Set (MDS) dated [DATE], indicated R129 had severely impaired cognition and was dependent on staff for their activities of daily living (ADLs). R129's Order Summary Report dated 1/20/25, indicated R129 had an order starting on 4/2/24 with no end date for nystatin (an antifungal medication) powder application to the groin two times a day for a rash. R129's Medication Administration Report (MAR) dated 1/1/25-3/3/25, indicated R129 had received twice daily applications of nystatin powder during this period. R129's Weekly Skin Evaluation dated 2/14/25, included a section where staff could check any of the following skin conditions: skin intact, dry, rash, plaques, callouses, redness, skin tears, blisters, open…

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 provide appropriate side effect monitoring with antipsychotic medication consumption related to residents who did not have an Abnormal Involuntary Movement Scale (AIMS) or orthostatic blood pressures for 1 of 3 residents (R183), and the facility failed to provide non pharmaceutical interventions prior to medication use for 1 of 3 residents (R204) reviewed for unnecessary medication use. Findings include: R183's quarterly Minimum Data Set (MDS) dated [DATE], indicated R183 had intact cognition. Diagnoses included hypertension and renal failure. R183's Order Summary Report (OSR) indicated on 12/16/24 an order was reviewed for Aripiprazole (antipsychotic mental health medication) 5mg orally to be given at night. The OSR also indicated orthostatic blood pressures one time a month for side effect monitoring, started 9/25/24. Lastly the OSR indicated on 9/25/24 an order for antipsychotic side effect monitoring that included side effects of increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to accommodate resident needs by ensuring call lights were within reach for 3 of 5 (R3, R4, R5) residents reviewed for call light usage. R3's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition with diagnoses that included dementia, muscle weakness and repeated falls. R3's care plan dated 1/20/25 lacked direction regarding call light usage. On 1/27/25 at 1:13 p.m., R3 was observed seated in her wheelchair with the call light cord lying in a coil on the floor behind her wheelchair. R3 stated she pushed her call light button when she needed help. She could not reach her call light and if she tried to pick it up off the floor, she would probably fall out of her wheelchair. On 1/27/25 at 1:20 p.m., registered nurse (RN)-A confirmed R3's call light button was out of her reach. All residents should have their call lights within reach before a staff person leaves the room. On 1/28/25 at 9:59 a.m., nursing assistant (NA)-B…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately assess a resident's skin condition for 1 of 3 residents (R3) reviewed. R3 was found to have an inflammatory skin condition on both of his hands and elbow that was not identified on R3's Minimum Data Set (MDS) and R3's assessments. Findings include: R3's admission nursing assessment dated [DATE] indicated R3's skin condition, temperature, turgor (skin elasticity), and integrity (health of the skin) were all normal. The assessment indicated R3 had redness to his coccyx (tailbone area), necrotic (death of tissues) of his second and third toes, a wound on the left foot and other skin discoloration. The assessment did not indicate where the skin discoloration was located or a description of it. R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 had a Brief Inventory of Mental Status (BIMS) score of 6 indicating R3 was severely cognitively impaired. R3 was dependent upon staff for dressing, grooming, and transferring. R3 did 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 provide timely notification of critical lab results to the physician for 1 of 3 residents (R3) reviewed for change in condition. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 was cognitively intact, with diagnoses of chronic kidney disease and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). R3 required an indwelling urinary catheter (tube inserted into the bladder to drain urine), and used anticoagulants (medications used to prevent blood clots from forming). R3's care plan dated 7/8/24 indicated R3 had an indwelling urinary catheter, and staff should monitor for blood-tinged urine. R3's Physician's Orders dated 10/28/24 directed to observe for symptoms of bleeding such as red or dark brown urine, and document unusual findings in the progress notes. R3's laboratory (lab) results dated 10/18/24, indicated R3 had a positive culture for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate catheter care and services to minimize the risk for urinary tract infections for 1 of 3 (R1) residents. Additionally, the facility failed to follow provider's orders when catheter required to be flushed for 1 of 1 (R1) residents reviewed with indwelling catheter. Findings included: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. R1 required partial to moderate assistance for personal hygiene, substantial to maximal assistance for repositioning, upper body dressing, and dependent upon staff for all transfers. R1 was unable to ambulate and used a motorized wheel chair for mobility. R1 had an indwelling urinary catheter and always incontinent of bowel. R1 diagnoses included neurogenic bladder (a condition that affects bladder control due to nerve damage or brain disorders), diabetes mellitus, multiple sclerosis (autoimmune disease in which the insulating covers of the nerve…

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 provide a dignified dining experience in the locked memory care unit dining room. This had the potential to effect all 36 residents and visitors. Findings include: During observation on 7/8/24 at 5:25 p.m., three residents were eating in the hall outside of the dining room on tray tables next to the nurse's station. Staff would occasionally provide cueing assistance. One resident was sitting in a chair in the corner eating off a knee height side table. Another resident sitting in a chair along the wall eating off a tray table. All spots at the tables in the dining room are utilized by other residents. During observation on 7/10/24 at 8:31 a.m., all residents are served meals on tray tables. All trays are left under the plates during the meal. Food is brought to unit on a cart, which is left in the dining room during the meal service. Three carts are present in the dining room by the door after all residents were served. All residents on the same table are not served at the same time. One resident had her food in front of her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure an appropriate safety plan was in place to protect residents of the facility while there was an ongoing investigation for an allegation of abuse. This had the ability to effect all residents on the units the allegated perpetrator worked on. Findings include: R145's significant change Minimum Data Set (MDS) dated [DATE], identified R145 had intact cognition and demonstrated no hallucination or delusional behaviors. During an interview on 7/9/24 at 3:34 p.m., R145 stated that a nurse worked on 7/6/24, and did her wound care was excessively rough poking and prodding unnecessarily into her wound causing more pain than usually occurred. R145 felt that the nurses were causing the extra pain on purpose and trying to abuse her physically. This was reported to the administrator so they could investigate the allegation of physical abuse. Review of wound care documentation from 7/6/24, indicated licensed practical nurse (LPN)-E was the nurse…

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 include individualized approaches for care, including non-pharmacological interventions to aid in the management of mood and behavior, in the comprehensive care plan for 1 of 5 residents (R67) reviewed for unnecessary medications. In addition, the facility failed to ensure dementia care was incorporated into the care plan for 1 of 2 residents (R184) reviewed for dementia care and failed to ensure accurate orders for 1 of 1 residents (R190) reviewed for range of motion. Findings include: R67: R67's significant change Minimum Data Set (MDS) dated [DATE], included R67 was cognitively intact, had diagnoses of Alzheimer's disease and depression, and took antipsychotic and antidepressant medications. The MDS indicated R67 did not exhibit any behaviors. R67's provider History and Physical dated [DATE], included R67 had severe major depressive disorder with psychotic features. R67's care plan dated [DATE], included R67 used psychotropic…

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 provide a safe, sanitary, comfortable environment for resident on the locked memory care unit. This had the potential to affect all 36 residents, staff and visitors. Findings Include: During interview on 7/8/24 at 1:42 p.m., family member (FM)-A stated the facility was always dirty and had an odor of urine in the hallways. FM-A stated she cleaned R169's room or it would be dirty also. On 7/8/24 at 3:07 p.m., the carpeted floor in the dining room on the unit was observed to have various crumbs and other debris. An approximately 2 x 2 inch piece of paper that was white and yellow was under one square table. Numerous small, light colored, powder-like spots around the whole room. On 7/8/24 at 6:30 p.m., R169 was standing in the hallway in the general area outside her room walking, occasionally touching objects such as the door, handrail, and wall. On 7/9/24 at 1:38 p.m., two light brown spots on the floor approximately 2 inches in diameter close to the wall…

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 physician's orders for self-administration of medication (SAM) and SAM occurred at the appropriate time for 1 of 1 resident (R173) reviewed for self-administration of medication. Findings include: R173's quarterly Minimum Data Set (MDS) dated [DATE], indicated R173 had intact cognition and diagnoses of cancer, respiratory failure, and chronic obstructive pulmonary disease (long-term lung disease which restricts airflow and causes breathing problems). MDS indicated R173 had no rejection of care and was independent with activities of daily living. R173 required tracheostomy care and suctioning. R173's physician's orders dated 7/11/24, identified Belbuca buccal (applied in the inner cheek) film 300 micrograms (mcg) with directions to place and dissolve 1 film buccally two times a day for pain. R173's physician's orders lacked orders for self-administration of medication. R173's SAM assessment dated [DATE], identified R173 knew their…

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

Based on document review and interview, the facility failed to provide smoking opportunities for 1 of 1 residents (R581) reviewed for choices. Findings Include: R581's admission Record printed 7/11/24, included diagnosis of weakness and dementia without behavioral disturbance. R581's Nursing admission Evaluation dated 6/20/24, included a section for tobacco use with a selected answer of yes for flame lite tobacco use. Smoking evaluation dated 7/1/24, included R581 wished to smoke during her stay at the facility. Resident wished to ulitized flame lit cigarettes. Resident was marked safe to smoke with limitations. R581's progress note dated 7/1/24, included the resident was observed smoking cigarettes in the hallway of the facility. Progress note dated 7/2/24, included the resident was able to express ideas and wants. Progress note dated 7/2/24, included the resident spent a lot of time looking for cigarettes and propelling self around until asking for cigarettes. Progress note dated 7/9/24, included the resident was asking to go out to smoke several times during the shift. R581's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 2 of 2 residents (R45, R143) who had been hospitalized . Findings include: R45's nurse's note dated 6/25/24, indicated R45 had been sent to the emergency room due to confusion and was admitted with possible sepsis. The physician's progress noted dated 7/3/24, indicated R45 was hospitalized with sepsis from 6/24/24 -7/1/24. The medical record lacked evidence notice of the transfer was provided to the OOLTC. R143's hospital Discharge summary dated [DATE], indicated R143 was hospitalized with sepsis from 6/17/24-6/26/24. The medical record lacked evidence of written notification of transfer were provided to the OOLTC. The June 2024 Ombudsman Report dated 7/1/24, identified 4 residents who had been transferred to the hospital in June 2024 . However, the report did not include R45 or R143. During interview on 7/11/24 at 11:41 a.m., the director of nursing (DON)…

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 provide notification to the resident and/or resident representative of the facility bed hold policy within 24 hours of an emergency transfer for 1 of 2 residents (R45) who required an emergency transfer to the hospital. Findings include: R45's nurse's note dated 6/25/24, indicated R45 had been sent to the emergency room due to confusion and was admitted with possible sepsis. The physician's progress noted dated 7/3/24, indicated R45 was hospitalized with sepsis from 6/24/24 -7/1/24. During interview on 7/8/24 at 03:21 p.m., R45 stated they had been recently hospitalized with sepsis but could not recall being notified of the facility bed hold policy. During interview on 7/10/24 at 09:08 a.m., registered nurse (RN)-H stated the nurse transferring a resident out of the facility was to notify the resident or their representative of the bed hold policy at time of transfer. RN-H confirmed R45's record lacked a bed hold notification for the 6/24/24, hospitalization. During interview on 7/11/24 at 11:41 a.m., the director 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 revise and update a comprehensive care plan for 1 of 2 residents (R45) reviewed for hospitalizations, and 1 or 3 residents (R45) reviewed for dialysis for services provided per plan of care. Findings include: R45's undated face sheet indicate R45 was admitted to the facility 2/28/24 with diagnoses including anemia (not having enough healthy red blood cells), heart failure (progressive heart disease that affects the pumping action of the heart), high blood pressure, and end stage renal failure (ESRD-advanced stage of chronic kidney disease when the kidneys can no longer filter wastes and fluids from the blood). R45's physician progress noted dated 7/3/24, indicated R45 was hospitalized with sepsis from 6/24/24 -7/1/24. R45's hospital Discharge summary dated [DATE] indicated R45 was hospitalized with bacteremia due to infected PCAD (a device used for dialysis) and subsequently had this device surgically removed on 6/25/24. R45's care plan 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 observation , interview and document review, the facility failed to provide bathing for 1 of 1 residents (R166) reviewed for activities of daily living (ADL's). Findings include: R166's admission minimum data set (MDS) dated [DATE], identified R166 was cognitively intact with diagnoses including depression, anxiety, end stage renal disease (ESRD), and unsteady gait. R166 was also identified as requiring partial assistance (staff does less than half of the effort) with bed mobility, transfers, and personal hygiene. R1 was totally dependent on staff for toileting. The MDS did not identify R166's ability to complete full baths or showers and indicated R166 did not display behaviors including refusal of cares. R166's care plan dated 4/10/24, directed the two staff members to assist with personal hygiene. The plan directed extensive assistance with bathing. During interview on 7/8/24, at 6:23 p.m. R166 stated they had not had a shower since arriving at the facility. R166 stated the therapy staff had tried to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure residents received timely follow-up treatment and care in accordance with professional standards of practice and provider's recommendations for 1 of 1 residents (R121) reviewed for appointments. The facility also failed to follow provider orders and administer a blood pressure medication only when outside certain parameters for 1 of 1 residents (R40) reviewed for quality of care. Additionally the facility failed to monitor vital signs as ordered for 2 of 3 residents (R73, R138) reviewed for nutrition and recognize nursing staff were documenting colostomy care as being provided to a resident that did not have a colostomy for 1 of 1 resident (R190). R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R57 was severely cognitively impaired. Diagnoses included hypertension and end stage renal disease, R40's provider orders dated 5/9/24 indicated R40 was started on Midodrine (a medication to increase the blood pressure when low), 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely assistance in repositioning and toileting for 1 of 1 resident (R138) reviewed for pressure ulcers. Findings include: R138's quarterly Minimum Data Set (MDS), dated [DATE] included diagnoses of dementia, hemiplegia (weakness on one side of the body), and malnutrition. R138 was dependent for toileting hygiene and dependent for chair to bed transfer. R138's MDS indicated she had moderate cognitive impairment. R138's care plan dated 5/2/24, identified R138 was incontinent of bladder and required assistance every 2-3 hours for incontinent care to remain free from skin breakdown. R138 had the potential for pressure ulcer development. During continuous observation on 7/10/24 from 7:35 a.m. to 11:16 a.m., R138 was observed in her wheelchair in the dining room. At 7:35 a.m., R138 was observed at the dining room table waiting for breakfast. At 9:54 a.m., R138 attended an activity in the dining room. At 11:08 a.m., resident remained…

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 post hospitalization assessment was completed for 1 of 1 residents (R45) who had their arteriovenous (AV) access site and hemodialysis treatment discontinued and also failed to ensure post-dialysis monitoring assessments were consistently completed and accurately documented to provide continuity of care and reduce the risk of complications for 3 of 3 residents (R45, R166 and R143) reviewed for dialysis care and services. Findings include: R45: R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated R45 was cognitively intact, and demonstrated no rejection of care behavior. The MDS indicated R45 was diagnosed with chronic kidney disease with dialysis. R45's order summary report dated 7/9/24, included the following current orders: -Hemodialysis (3) times per week on Tuesday, Thursday, and Saturday. Venous access site: care and dressing change during dialysis days and as needed (per dialysis). The order start date 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 record review the facility failed to develop and implement dementia care as part of the comprehensive care plan for 1 of 3 residents (R184) reviewed for dementia care. Finding include: R 184's quarterly Minimum Data Set (MDS) dated [DATE], quarterly indicated R184 had moderate cognitive impairment with the diagnoses of chronic obstructive disease, major depressive disorder recurrent, and dementia. R184's care plan listed as last reviewed on 4/17/24, lacked evidence of individualized interventions to support R184's dementia diagnosis. In addition, the care plan lacked evidence of interventions for mental health needs and management. During an interview on 7/11/24 at 1046 a.m., registered nurse (RN)-A confirmed R184 had a diagnosis of dementia. After review of the electronic medical record (EMR) and the paper chart, RN-A confirmed R184's care plan did not include interventions for dementia care or mental health needs. During an interview on 7/11/24 at 2:10 p.m., the director of nursing (DON)…

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 identify individualized approaches for care, including non-pharmacological interventions to aid in the management of mood and behavior, for 2 of 5 residents (R67, R184) reviewed for unnecessary medications. Findings include: R67: R67's significant change Minimum Data Set (MDS) dated [DATE], included R67 was cognitively intact, had diagnoses of Alzheimer's disease and depression, and took antipsychotic and antidepressant medications. The MDS indicated R67 did not exhibit any behaviors. R67's provider History and Physical dated [DATE], included R67 had severe major depressive disorder with psychotic features. R67's care plan dated [DATE], included R67 used psychotropic medications for behavior management and depression, and R67 had a behavior problem relating to sitting in a chair with a blanket over their head. The care plan lacked resident-specific interventions to address R67's mood and behaviors. R67's Psychotropic Drug Use Care Area assessment 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 and document review, the facility failed to ensure 3 of 5 residents (R6, R45, R202) were offered or received pneumococcal vaccination in accordance to Center for Disease Control (CDC) recommendations. 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 PCV-20 at least 1 year after prior PCV-13, b) the 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 turns [AGE] years old. 2) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 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, observation and document review, the facility failed to review a progress note from a physician's appointment for 1 of 4 residents (R1). The progress note identified suicidal ideation and physical abuse allegations, putting R1 at risk for harm from self or others. Findings include: R1's face sheet dated 6/7/24, indicated R1 had diagnoses of adult failure to thrive, cirrhosis of liver, neoplasm of breast, depression, unspecified symptoms and signs involving cognitive function, cognitive communication deficit and dementia. R1's 5-day Minimum Data Set (MDS) assessment dated [DATE] identified R1 was significantly cognitively impaired and required assist of 1 to 2 staff for activities of daily living. R1's patient health questionnaire (PHQ-9) dated 6/3/24 indicated R1 had little interest or pleasure in doing things, was feeling down, depressed, or hopeless, was feeling tired and had thoughts that she would be better off dead or hurting herself in some way over the past two weeks. R1'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 interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R5). Findings include: R5's facesheet dated 5/15/24, indicated R5 was admitted on [DATE] with diagnoses including end stage renal (kidney) disease (ESRD, when a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of dialysis or a kidney transplant to maintain life), type 2 diabetes with diabetic chronic kidney disease, mild protein-calorie malnutrition, and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly). R5's provider orders included an order dated 4/15/24, for weight once daily in the morning, call physician if weight increased by two pounds in 24 hours or five pounds in seven days from admission weight. R5's electronic health record (EHR) included…

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 initiate oxygen orders for 3 of 5 residents (R2, R3, R4) and bilevel positive airway pressure (BiPAP, delivers pressurized air to the lungs) orders for 1 of 1 resident (R5) reviewed for respiratory care. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. R2's Diagnosis List printed 11/30/23, included multiple sclerosis and hypoxemia. R2's Provider Orders dated 06/05/23, indicated an order for oxygen: 2 liters of supplemental oxygen via nasal cannula to keep oxygen saturations at or above 90%. R2's care plan lacked a plan for oxygen use. R2's electronic medical record (EMR) lacked progress notes for the 11/30/23, day shift to assess oxygen use. On 11/30/23 at 10:33 a.m., R2 was observed in her room with 3 liters of supplemental oxygen delivered by nasal cannula, although the order indicated 2 liters. On 11/30/23 at 11:13 a.m., licensed practical nurse (LPN)-A verified R2's oxygen…

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 observations, interview and document review, the facility failed to follow professional standards following the correct procedure as ordered for 1 of 1 resident (R3) who received lymphedema wraps (multilayer wraps to add compression to excess fluid to assist in circulation). R3 had multiple orders with different procedures for his lymphedma wraps that staff provide treatment of. Findings include: R3's signed physician order dated 7/17/23 indicated 1. Occupational Therapy (OT) to evaluate and treat for lymphedema wraps. 2. Later left lower extremity (LLE) wound care: Clean lower extremity with wound cleanser, pat dry, cover open area with absorbent dressing. Complete wound care with lymphedema wrap changes. R3's signed physician order dated 7/19/23 indicated OT to evaluate because worsening of lower extremity lymphedema. Wrap legs with ace bandage, elevate. R3's signed physician orders dated 8/23/23 indicated 1. Discontinue previous lower tibia wound care orders. 2. Wound care: Left lower extremity clean…

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, interviews and record review the facility failed to disinfect reusable medical equipment consistent with accepted standards of practice for 2 of 2 residents (R3) and (R4) observed following personal cares. The facility had 52 positive COVID-19 cases. Findings include: A Minnesota Department of Health (MDH) website dated 10/22/23 https://www.health.state.mn.us/facilities/patientsafety/infectioncontrol/pre/standard.html indicated standard precautions are the basic level of infection control that should be used in the care of all patients all the time. Patient care equipment identified equipment is to be cleaned, disinfected, or reprocess non-disposable equipment before reuse with another patient. R3's care plan dated 7/1/23, indicated R3 transferred with an EZ-stand (a transfer-assist machine which actively engages the patient in the standing process.) R3's significant change Minimum Data Set (MDS) dated [DATE] indicated R3 had a Brief Inventory of Mental Status (BIMs) score of 10 indicating…

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 was provided for 1 of 2 residents (R105) reviewed who were dependent on staff for personal cares. Findings include: R105's Quarterly Minimum Data Set (MDS) dated [DATE] identified R105 required extensive assistance with bathing and personal hygiene. R105's cognition was intact. R105's care plan dated 10/13/21 indicated assistance of one person for personal hygiene. R105's admission record printed 9/27/23 included diagnoses of diabetes mellitus and need for assistance with personal care. R105's Task on treatment administration record (TAR) dated September 2023 read to ensure weekly bath and skin assessment were completed every Thursday. Task was marked as complete 9/7/23, 9/14/23 and 9/21/23. On 9/25/23 at 1:38 p.m., R105 stated she wanted her toenails trimmed. Toenails on right foot were approximately 1/8 inch past end of toes, clean and not thick. On 9/27/23 at 11:32 a.m., NA-C stated the licensed nurse would complete…

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 2 of 3 (R1 & R3) residents reviewed for comprehensive care plans had developed and implemented person-centered care plans. Findings include: R1's care plan initiated on 5/1/23, noted R1 required total assistance of a mechanical lift for transfers, suicidal ideation on 8/4/23, and that R1 was at risk for falls with a fall risk score of 10 or greater due to gait and balance problems initiated on 8/31/23. The associated goals and interventions were not personalized for either suicidal ideation or fall risk and contained place holders such as specify, I need, the resident needs, [PREFERRED NAME] needs a safe environment with: (specify: even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light .). An intervention for his suicidal ideation noted ACP (Associated Clinic of Psychology) consult. R1's quarterly Minimum Data Set (MDS) dated [DATE], noted R1 had intact cognition, 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 document review, the facility failed to provide incontinence care for 1 of 3 residents (R2) who were totally dependent on staff for activities of daily living (ADLs). Finding include: R3's admission Record dated 5/22/23 indicated R3' diagnoses included Parkinson's disease, cervical myelopathy, right femoral head fracture and dislocation. R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 was diagnosed with Parkinson's disease, required total assistance with ADLs, and had moderate cognitive impairment. R3's care plan dated 5/22/23 indicated R3 was totally dependent on staff, and staff was to check R3 every two hours and assist with toileting as needed. On 8/16/23, at 12:35 p.m., R3 was observed in bed uncovered, with the head of the bed elevated. R3's incontinence brief was moderately soaked with urine. R3's bed sheet and his gown were both soaked with urine. No staff was noted in the room at this time. On 8/16/23, at 12:45 p.m. R3's family member (FM)-A stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer/provide oral cares, shaving, and brushing of hair for 1 of 4 residents (R1) reviewed for activities of daily living (ADLs) and who was dependent on staff for cares. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, required extensive assistance with personal hygiene, and displayed no rejection of care behaviors. R1's care plan dated 7/26/23, indicated R1 needed assistance with washing, dressing, and grooming and to encourage R1 to participate as able. During observation and interview on 7/31/23 at 10:48 a.m., R1 was in bed wearing a gown. Family member (FM) was visiting and stated they were not sure if staff had cleaned R1 up yet today. During observation on 7/31/23 at 2:13 p.m., NA (nursing assistant)-A and NA-B assisted R1 with cares by turning and repositioning R1 while R1 was in bed. NA-A provided R1 with a washcloth, and R1 used the washcloth to wash face. NA-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 routinely provide and document range of motion (ROM) exercises to maintain and prevent decline in current physical functioning for 1 of 2 residents (R1) reviewed for restorative therapies. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition and diagnoses of multiple sclerosis and a seizure disorder. R1 needed extensive to total assistance with most activities of daily living (ADL's). R1 had impairments to both sides of upper and lower extremities and no rejection of cares. There were zero days in which restorative nursing programs were provided during the seven-calendar day look-back. R1's care plan dated 7/26/23, directed staff to provide gentle range of motion as tolerated with daily care. R1's physician orders dated 2/9/23, indicated for physical, occupational, and speech therapy to eval and treat for strengthening and weakness. R1's physical therapy Discharge summary…

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 secure a suprapubic catheter tubing and prevent skin complications for 1 of 1 resident (R1) reviewed for catheter care. Findings include: R1's quarterly Minimum Data Set, dated [DATE], included diagnoses of neurogenic bladder and multiple sclerosis. R1 had moderately impaired cognition and needed extensive to total assistance with most activities of daily living (ADL's). The MDS indicated R1 had an indwelling catheter. R1's face sheet dated 8/2/23, included diagnosis of retention of urine. The Care Area Assessment (CAA) with unknown date, indicated the care plan would address minimizing risks associated with the use of an indwelling catheter. R1's physician order dated 2/9/23, indicated staff monitor and assess for signs and symptoms of catheter related complications including penile erosion two times a day. If complications noted, staff to update the MD/NP for additional interventions. R1's care plan dated 7/26/23, indicated suprapubic…

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.