The Villas At Osseo LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide assistance with grooming for 1 of 2 resident (R145) reviewed for activities of daily living (ADL's). Findings include: R145's admission Minimum Data Set (MDS) dated [DATE], indicated R145 was cognitively intact and required assistance with ADL's. R145 had diagnosis of acute kidney failure and moderate protein calorie malnutrition. R145's care plan dated 5/27/25, indicated. R145 required assistance with personal hygiene preferences. The care plan revealed R145 would be dressed and groomed per his preferences. During an observation on 6/9/25 at 3:02 p.m., R145 was lying in bed watching television. R145's beard and mustache were approximately one inch long. R145 stated the beard and mustache were long for him. R145 stated he would like it to be clean shaven, he would look better. An interview on 6/10/25 at 1:29 p.m., nursing assistant (NA)-A stated it was part of resident care to offer shaving. NA-A stated she did not offer R145 to…

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

Based on observation and interview the facility failed to ensure medications were secured in resident accessible areas. In addition, the facility failed to ensure medications were labeled with current physician-ordered administration instructions including medication name, and resident name. This unsafe practice had the potential to impact residents who received medications from the 100-unit medication cart. Findings include: During an observation on 6/11/25 at 8:22 a.m., licensed practical nurse (LPN)A administered medications from the 100-unit medication cart to R26. LPN-A placed a blue cup with an unlabeled, undated medication syringe containing a clear liquid and an unlabeled, undated clear medication cup with a round tablet on R26's bedside table while LPN-A administered crushed medications. After R26 took the crushed medications she asked LPN-A what the medications on the bedside table were. LPN-A stated the syringe in the blue cup contained liquid methadone for pain and the pill was lorazepam. R26 shook her head no, and stated she did not want them. LPN-A then picked up 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.

Based on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding dignity, which was also identified during this survey. This had the potential to affect all 85 residents in the facility. Finding include: Review of the [NAME] Report 0003D Provider History Profile Report dated 5/16/25, indicated the facility was cited for F550 for dignity during the survey exited 9/24/24. See F550: Based on observation, interview, and record review, the facility failed to utilize professional interpretive services for 1 of 1 resident (R66) reviewed for oral communication. The facility's QAPI minutes dated 3/20/25, 4/17/25, and 5/15/25 lacked ongoing data related to the above repeat citation related to dignity concerns. On 6/12/25 at 1:22 p.m., the administrator stated the QAPI committee meets monthly, and they use standard monarch documentation to trend and identify problematic areas for opportunities to improve. 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.

Based on observation and interview, the facility failed to complete proper hand hygiene during 2 of 3 dining observations. This had the potential to affect all 85 residents. Findings include: During dining observation on 6/10/25 at 8:16 a.m., director of nutrition (DN) completed hand hygiene with soap and water for about 5 seconds in the dining room serving area. During interview at 6/10/25 at 8:20 a.m., DN stated she washed her hands for approximately 10 seconds. DN stated she believed proper hand hygiene should take 15 seconds, but felt it was not an issue because she was not touching food, only checking temperatures and adjusting serving dishes in the steam table. During food prep observation on 6/12/25 at 10:05 a.m., dietary aide (DA)-A checked the chemical level on the dishwasher, washed hands with soap and water for 6 seconds, dried hands and replaced gloves. During observation and interview on 6/12/25 at 10:21 a.m., DA-B entered the kitchen, washed hands with soap and water for 7 seconds, put on gloves and started moving clean dishes to storage area. DA-B stated she should…

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 (R12, R61, and R65) were offered, educated on, and provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Adult Immunization Schedule by age topic, dated 11/21/2024, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was admitted on [DATE], was able to communicate clearly and understand others, was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to notify resident representative timely following resident change of condition for 1 of 1 residents (R2) who had a weight loss of eight pounds in 27 days. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had cancer, diabetes mellitus, heart failure, seizure disorder and depression. The MDS indicated R2 was cognitively intact with no mood or behavior disorders, was independent with activities of daily living (ADL), including eating. R2's weight was 200 pounds (lbs) indicating, no weight loss with a therapeutic diet. R2's care plan (CP) dated 3/11/24, indicated nutritional problems or potential nutritional problems related to increased nutritional needs due to a diagnosis of malignant neoplasm (cancerous tumor) of left breast, increased protein needs, supplements discontinued by physician, weight stable for 180 days. The care plan directed staff to allow resident sufficient time to eat, evaluate weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to comprehensively assess and implement appropriate pain monitoring to ensure comfort for 1 of 1 residents (R1) reviewed for pain management and whom was non-verbal and unable to communicate their needs. Findings include: R1's admission Minimum data Set (MDS) dated [DATE], had no MDS entries due to death on [DATE]. R1's care plan (CP) dated [DATE], indicated R1 received palliative care (focusing on improving quality of life for those with serious illnesses, during end-of-life care specifically focuses on the final months, weeks, or days of life), pneumonia, obesity due to excess calories, hypertension congestive heart failure, atrial fibrillation and long term use of insulin. In addition, R1's CP indicated he received hospice services as of [DATE], and comfort cares as desired with verbalized satisfaction with cares received. Additionally, R1's CP indicated he had alteration in cognition, mobility, mood and comfort, and directed staff to provide…

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 side rails were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of bed rails for 2 of 3 residents (R2, R3) who were observed to have side rails raised on their beds. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated intact R2 had cognition. Diagnoses included repeated falls, and type 2 diabetes with foot ulcer. R2 was independent with bed mobility and required substantial staff assistance for transfers. R2's care plan dated 1/10/25 indicated R2 required assistance with bed mobility, and was transferred with assist of two staff members and a mechanical standing lift. R2's care plan lacked information about bed rails. R2's electronic medical record (EMR) lacked evidence a side rail assessment had been completed to determine necessity, and whether R2 could safely use side rails. Additionally, R2's EMR 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 observation, interview and document review, the facility failed to communicate in a dignified manner to 1 of 1 residents (R2) reviewed for dignity. Finding include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had depression, paraplegia (inability to voluntarily move the lower parts of the body), hemiparesis ( one-sided muscle weakness) and hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). The MDS further indicated R2 was cognitively intact, no behaviors and daily preferences were very important. In addition the MDS indicated R2 had impairment to upper and lower extremities on one side, needed maximum assistance with toileting, dressing, mobility and used a wheelchair. R2's Care Plan dated 10/24/24, indicated R2 was a smoker at the facility and was fall risk due to contracture to left ankle. The Care Plan further indicated R2 had a fall on 8/16/24, and staff were to accompany resident after meals to smoking…

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 resident representative timely following resident falls with injury for 1 of 1 residents (R3) who had been hospitalized twice from falls, one with hip fracture and then a neck fracture. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 had diagnosis of dementia, had mild cognitive impairment, demonstrated no verbal or physical or verbal behaviors, and had no rejection of care episodes. The MDS indicated R3 required partial assistance with activities of daily living, had a fall since admission with no injury, had surgery involving the gastro intestinal (GI) track and received anti-psychotic medications. R3's Care Plan (CP) dated 11/07/24, indicated C3 was at risk for falls related to gall bladder surgery, muscle weakness, unsteadiness on feet, muscles wasting and atrophy in shoulders, dementia. In addition the CP indicated R3 does ambulate self in room. The CP interventions included the following: -Physical…

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 complete the initial comprehensive assessment using direct observation and communication with the resident for 1 of 1 resident (R3) reviewed for falls. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 had diagnosis of dementia, had mild cognitive impairment, demonstrated no verbal or physical or verbal behaviors, and had no rejection of care episodes. The MDS indicated R3 required partial assistance with activities of daily living, had a fall since admission with no injury, had surgery involving the gastro intestinal (GI) track and received anti-psychotic medications. A Fall Review Evaluation dated 10/21/24, indicated R3 was admitted on [DATE], had a history of multiple falls, received narcotics, psychotropics. The Evaluation further indicated R3 exhibits loss of balance while standing, required bide base of support, frequently incontinent of urine, wandering less than daily and confined to chair daily.…

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 update the care plan with identified fall interventions for 1 of 3 residents (R3) reviewed for falls. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 had diagnosis of dementia, had mild cognitive impairment, demonstrated no verbal or physical or verbal behaviors, and had no rejection of care episodes. The MDS indicated R3 required partial assistance with activities of daily living, had a fall since admission with no injury, had surgery involving the gastro intestinal (GI) track and received anti-psychotic medications. R3's Care Plan (CP) dated 11/07/24, indicated R3 was at risk for falls related to gall bladder surgery, muscle weakness, unsteadiness on feet, muscles wasting and atrophy in shoulders, dementia. In addition the CP indicated R3 does ambulate self in room. The CP interventions included the following: -Physical therapy (PT) per orders -Follow PT and Occupational (OT) instructions for…

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

Based on observation, interview and document review, the facility failed to provide medication as ordered by the physician for 3 of 3 residents (R1, R2, R3) reviewed for pharmacy services. Findings include: R1's Physician's Orders dated 8/21/24 directed to hold warfarin (generic name for Coumadin, a blood thinner) 8/21/24 and 8/22/24. Recheck INR (international normalized ratio, a lab test for blood clotting) on Friday 8/23/24. R1's August MAR indicated R1 did not receive Coumadin from 8/23/24 through 8/27/24. On 9/6/24 at 12:25 p.m., case manager (CM)-A stated licensed practical nurse (LPN)-C entered the order into the computer system incorrectly, which lead to the omission of the lab being completed as ordered. R1 missed Coumadin dosages 8/23/24 through 8/27/24. On 9/10/24 at 9:04 a.m., LPN-C stated she made an error when entering the lab order into the computer system, for R1's INR, causing it to be missed on 8/23/24. R2's Physician's Orders dated 9/4/24 directed to administer niacin (a form of vitamin B3) 500 milligrams (mg) by mouth daily in the morning. On 9/5/24 at 7:26 a.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 maintain infection control practices while conducting blood glucose checks for 2 of 4 patients (R1, R4) reviewed for medication administration. Findings include: R1's MDS admission Minimum Data Set, dated [DATE] indicated R1 had a diagnosis of diabetes mellitus. R1's Physician's Order dated 8/31/24, directed to check blood glucose before meals and at bedtime. On 9/6/24 at 11:41 a.m., licensed practical nurse (LPN)-A placed a bin containing blood glucose testing supplies, including a shared glucometer, on the nightstand in R1's room. LPN-A placed the glucometer on the bed linens while she prepared R1's finger, then set the glucometer on the over-the bed table once she had the blood sample applied to the test strip. LPN-A removed the test strip and wiped the glucometer with an alcohol wipe, and immediately placed the glucometer back in the bin. LPN-A stated she was not aware of any other cleaning requirements for the glucometer other than…

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 utilize professional interpretive services for 1 of 1 residents (R66) reviewed for oral communication. Findings include: R66's Quarterly Minimum Data Set (MDS) dated [DATE], included diagnosis of psychotic disorder, post traumatic stress disorder, anxiety disorder, and stroke. R66 was cognitively intact. R66 was listed as having pain frequently. R66's order summary report dated 8/22/24, included contact information for [NAME] Interpreter Services. Order included phone number, pin number for access, resident spoke Ukrainian, and to utilize as needed. R66's care plan dated 7/11/24, included resident has a risk for alterations in behavior due to trauma and PTSD. Care plan included to communicate via interpreter and to consider past trauma when engaging with the resident. Care plan included R66's primary language was Russian and to utilized translator app on phone to communicate. During interview on 8/19/24 at 5:01 p.m., R66 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, and interview the facility failed to ensure a written notification of transfer and/or discharge was sent to the office of the Ombudsman for 1 of 4 (R30) reviewed for hospitalization and/or discharge. Findings include: R 30's significant change Minimum Data Sset (MDS) dated [DATE], indicated R30's diagnoses included: high blood pressure, renal insufficiency (poorly functioning kidneys), diabetes, cerebral vascular accident (CVA) (stroke), aphasia (difficulty understanding or expressing words), hemiplegia (weakness of one side of the body), anxiety, depression, and chronic obstructive pulmonary disease (COPD) (long-term obstruction of airways). R30's census list dated 8/22/24, indicated R30 was hospitalized from [DATE] through 5/10/24. R30's medical record lacked evidence a written notification of transfer/discharge was sent to the office of the Ombudsman for long term care. On 8/22/24 at 10:32 a.m., the administrator approached surveyor and provided a list of ombudsman notifications 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.

Based on interview and document review, the facility failed to ensure a level II preadmission screening and resident review (PASARR) was completed for 1 of 1 residents (R25) residents reviewed with a serious mental illness diagnosis. Findings include: R25's quarterly Minimum Data Set (MDS) dated indicated R25 had diagnoses to include anxiety disorder and schizophrenia (a chronic and sever mental disorder that affects how a person thinks, feels, and behaves). R25's medical record revealed a level I PASARR was completed on 5/12/23 prior to admission and indicated a PASARR level II was required before R25 admitted to a nursing facility. No level II PASARR was found. During interview on 8/22/24, at 8/:49 a.m. social worker (SW)2 stated the normal process included having a level II PASARR completed prior to admission. SW-2 stated she had not had any communication with the lead agency regarding a level II PASARR in several months and it was inappropriate to not have it completed prior to admission. During interview on 8/22/24, at 9:43 a.m. the administrator stated the social services team…

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, facility failed implement interventions to prevent further development of decreased range of motion and ability for 2 of 2 residents (R17, R51) reviewed for positioning and mobility. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], included a primary diagnosis of Parkinson's disease (a progressive neurological condition). R17's MDS included limited range of motion (ROM) on both upper and lower extremities and dependent for mobility. R17's admission record printed 8/22/24, included diagnosis of contracture of the left ankle and foot. During observation on 8/19/24, R17's feet were noted to not be resting on the wheelchair foot pedals. R17's left foot was noticeably turned inward. No brace or positioning device was observed. R17's physical therapy Discharge summary dated [DATE], included recommendation R17 would benefit from daily stretches. A functional maintenance program was established, and staff were trained. R17's Order…

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 document review and interview the facility failed to report to the State Agency (SA) a injury of a hematoma on right leg for 1 of 1 (R1) when reviewed for injury of unknown origin. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE] indicted intact cognition (13)and diagnosis of acute kidney disease, anxiety disorder, muscle weakness, difficulty walking, need for assistance with personal care, type 2 diabetes mellitus, insomnia, delirium and, acute and chronic respiratory failure with hupercapnia and hypoxia. R1's incident report dated 7/9/24 indicated during AM cares, while the staff assisted the resident with transfer from bed to a wheelchair (W/C), the resident sustained a bruise on her left lower extremities (LLE). Reported indicated the Root cause as full body lift was defective and did not function properly, leading to the incident. Intervention indicated as the full-body lift was removed from the floor and dismantled by maintenance. Another full-body lift was rented.…

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 thoroughly investigate an injury of unknown origin (hematoma on right leg) for 1 of 1 resident (R1) reviewed for abuse. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE] indicted intact cognition (13)and diagnosis of acute kidney disease, anxiety disorder, muscle weakness, difficulty walking, need for assistance with personal care, type 2 diabetes mellitus, insomnia, delirium and, acute and chronic respiratory failure with hupercapnia and hypoxia. R1's care plan dated 6/12/24, indicated R1 required assist of 2 staff with transfer using full body lift, incident on 7/9/24: during transfers, R1 will need 3 staff members. One will guide legs, one will control the machine, other will assist R1 with wheelchair positioning behind her. R1's progress note dated 7/12/24 indicated at about 10:10 a.m. nursing assistant (NA)-A notified registered nurse (RN)-A that R1 had a lump on her leg and was screaming in pain. R1 was assessed and 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.

Based on interview and document review, the facility failed to allow a resident/resident's legal representative to participate in treatment decisions for 1 of 1 resident (R1) who was on hospice, had a seizure and was initially denied access to medical treatment at a hospital. Findings include: R1's minimum data status (MDS) undated, was not completed due to admit date of 3/06/2024 and discharge date of 3/09/2024. R1's Care Plan dated 3/07/24, indicated R1 had malignant carcinoid tumor of the sigmoid colon, restless leg syndrome, chronic obstructive pulmonary disease, anxiety disorder, malignant neoplasm of the rectum stage IV (The earliest stage of colorectal cancers is called stage 0 (a very early cancer), and then range from stages I (1) through IV (4)). In addition, R1's care plan indicated a coccyx wound on buttock staff were directed to turn and reposition every two hours with weekly skin inspections by a nurse. R1's care plan also indicated she had alteration in cognition and was forgetful, on hospice care related to diagnosis of stage IV metastatic rectal cancer, and resident…

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

Based on interview and document review, the facility failed to ensure a potential allegation of neglect was recognized and reported to the State agency (SA) in a timely manner for 1 of 1 resident (R1) reviewed. Findings include: R1's minimum data status (MDS) undated, was not completed due to admit date of 3/06/2024 and discharge date of 3/09/2024. R1's Care Plan dated 3/07/24, indicated R1 had malignant carcinoid tumor of the sigmoid colon and malignant neoplasm of the rectum stage IV (The earliest stage of colorectal cancers is called stage 0 (a very early cancer), and then range from stages I (1) through IV (4). Review of an email received by the Monarch Group on 3/10/24 at 1:42 a.m. indicated concerns related to the care of R1 for services provided during the date of 3/7/24-3/9/24. The email indicated a summary of the following: -Unsanitary room conditions -Unsafe room conditions (exposed electrical wiring) -bruising and bleeding in mouth related to forceful medication administration -wait times to use bathroom/delayed patient care times -patient rights concerns related to 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.

Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders for 10 of 10 residents (R2, R5, R7, R10, R11, R13, R16, R19, R20, R21) who were provided medications outside of ordered parameters by three staff on three separate units. Findings include: Resident Medication Admin Audit Reports identified the following medication order information for 4/2/24: -R7: 8:00 a.m. - metformin twice day (BID) with meals for diabetes (DM), metoprolol (cardiac), lorazepam (antianxiety) three times a day (TID), two antipsychotic medications for schizophrenia (haloperidol lactate and quetiapine fumarate), and two bowel medications. -R11: 8:00 a.m. - Lasix and Aldactone for edema, aspirin for stroke prevention, Breo Ellipta inhaler for COPD (Chronic obstructive pulmonary disease)(chronic inflammatory lung disease that causes obstructed airflow from the lungs) and a bowel medication. -R13: 8:00 a.m. - vilazodone with a meal for schizoaffective disorder, metformin with meals BID for DM, glipizide for DM, gabapentin…

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 insulin (blood sugar regulator) medication was administered in accordance with physician orders for 4 of 4 residents (R9, R15, R18, R20) who were provided insulin outside of ordered parameters and manufacturer recommendations by two staff on two separate units. Findings include: Resident Medication Admin Audit Reports identified the following provider insulin and blood sugar (BS) orders and scheduled time frames for 4/2/24: -R9: Novolog per sliding scale, based on corresponding ordered BS readings, before meals and at bedtime (HS) for diabetes mellitus (DM). The lunchtime Novolog was scheduled for 11:30 a.m. and supper scheduled at 5:30 p.m. -R15: Lispro per sliding scale, based on BS Dexcom 7 (continuous glucose monitoring system) readings, with meals for DM. The morning Lispro was scheduled for 7:30 a.m. with lunch scheduled at 12:30 p.m. -R18: 1. Humalog per sliding scale, based on Libre BS sensor device readings, three times a day (TID) for DM with first dose scheduled for 7:00 a.m. and second…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to implement comprehensive care plans for 1 of 1 residents (R1) reviewed for toileting and falls. Findings include: Vulnerable adult maltreatment report dated 2/22/24, indicated R1 was not provided with timely toileting. R1 face sheet identified R1 had diagnoses that included anoxic brain damage, muscle weakness, difficulty in walking, fall from bed, and unspecified fall. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitive and did not have behaviors. R1 required partial/moderate assistance to transfer on and off the toilet and was dependent for toileting hygiene. R1 was not on a toileting program and frequently incontinent of urine and bowel. R1's bladder evaluation dated 1/31/24, reviewed on 2/1/24. Identified R1 was not content of bladder and potential causes include weakness and limited mobility. R1 had functional incontinence (impaired mobility, manual dexterity impairment, lack of toilet or toilet…

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 safe transfers to prevent or mitigate the risk of falls and/or injury for 2 of 4 residents (R4, R1) reviewed for falls. Findings include: R4's face sheet identified R4 had diagnoses that included abnormalities of gait and mobility, dementia, muscle weakness, unsteadiness on feet and repeated falls. R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was to walk with a walker. R4 required partial/moderate assistance to go from sit to stand. R4's care plan dated 8/31/23, identified R4 required assist with transfers with the use of sit-to-stand mechanical lift. R4's therapy note dated 2/6/24 identified R4 required several standing rest breaks throughout ambulation. R4 ambulates with shuffling festinating gait, was occasionally able to achieve foot clearance but not consistently. R4 required moderate assist to stand from wheelchair. R4's nursing assistant care guide undated provided on 2/29/24 by administrator identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the therapeutic recreational director TRD-(A) was trained or had demonstrated competency prior to assisting residents with transfers, locomotion on/off unit, dressing, and ambulation for 1 of 1 residents (R4) reviewed for falls. Findings include: R4's face sheet identified R4 had diagnoses that included abnormalities of gait and mobility, dementia, muscle weakness, unsteadiness on feet and repeated falls. R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was to walk with a walker. R4 required partial/moderate assistance to go from sit to stand. R4's care plan dated 8/31/23, identified R4 required assist with transfers with the use of mechanical sit to stand lift. During observation on 2/29/24 at 9:02 a.m., R4 was walking out of the dining room with a four wheeled walker that had a seat. R4 stated to therapeutic recreation department director (TRD)-A My legs aren't working. TRD-A instructed R4 to sit on the seat of the four…

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 properly label and date food items removed from their original boxes, rotate food items prior to their expiration date, and reduce the risk of physical contamination of food related to poor personal hand hygiene which had potential to affect all 79 residents. Findings include: During the initial kitchen tour on 9/5/23 at 11:42 a.m., the refrigerator in the kitchen contained a single container of Hormel hydrolyte thickened water which had a black, fuzzy substance on the bottom inside of the container. The container had 10/27 written on it. During interview on 9/5/23 at 12 p.m., the culinary services director (CD) stated they rotate everything in and out, so they know what food and items to use first. The CD stated 10/27 on the Hormel hydrolyte thickened water was the date the thickened water was delivered. However, was not sure when it was last used. During observation and interview on 9/5/23 at 12:07 p.m., the walk-in freezer contained: 1. Three unopened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a preadmission screening and resident assessment and review (PASARR) level 2 had been completed for 1 of 1 resident (R22) reviewed for PASARR level 2. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder. Facility document titled, Senior 'LinkAge Line dated 5/12/2023, indicated yes for R22 having a current diagnosis of a developmental disability or related condition. Yes for R22 having been considered to have a developmental disability or related condition. Yes for R22 to have cognitive or behavioral signs that would lead someone to suspect the presence of developmental disabilities or related conditions. Yes for R22 to have a current diagnosis of a mental illness. Yes for R22 needing supportive services or interventions due to mental illness to maintain functioning within the past two years. The document…

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 revised and update comprehensive care plan and assessments for 1 of 3 resident (R21) reviewed for comprehensive care plans. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R21's had intact cognition and diagnoses which included: Generalized Anxiety Disorder, Type 2 diabetes mellitus without complications, major depressive disorder, and heart failure. R2 required physical assistance from one staff for bed mobility, dressing, personal hygiene, and bathing. R21's care plan printed 8/18/23, displayed all focus areas/goals and interventions were canceled/resolved on 8/18/23 and had a re-initiated date of 9/6/23. R21 had a 48-hour care plan initiated on 8/18/23, In Progress and never fully completed. During interview on 9/7/23, at 2:16 p.m., assistant director of nursing (ADON) stated the facility was in the process of updating resident's care plans to the new owner's care plans. ADON stated she received direction from 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 follow physician orders, document for proper positioning and use of assistive devices for 1 of 3 residents (R1) reviewed for assessment. R1's Annual Minimal Data Set (MDS) dated [DATE], indicated intact cognition (able to fully understand). Diagnoses of other neurological conditions (Issues with brain and spine) cerebral palsy (difficulty controlling muscles), and schizophrenia (twisted sense of reality). R1 was totally dependent of cares with impaired range of motion to both upper extremities (arms). R1's most recent orders with active date of 4/14/12 indicated to use a right upper extremity hand splint for contracture management (reducing painful muscle stiffening) Facility provided treatment administration record (TAR) for month of September 2023 failed to identify R1 refused to wear a splint or assistive device to either arm. On 9/6/23 at 5:48 p.m., R1 was in wheelchair after eating in the dining room. R1 lacked arm splint to either…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to have a current treatment order for 1 of 1 resident (R21) reviewed for physician orders. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnosis of Type II diabetes mellitus without complications. R2 required physical assistance from one staff for bed mobility, dressing, personal hygiene, and bathing. R21's care plan dated 8/18/23, indicated diabetes mellitus and required monitoring of blood sugars per MD order. The electronic health record (EHR) indicated R21's blood sugars had been obtained twice daily from 8/25/23 through 9/7/23. However, lacked orders for blood sugar monitoring. During interview on 9/6/23 at 9:57 a.m., R21 stated the nurse checked her blood sugars. She was unaware why. R21 stated she had asked but no one had gotten back with an answer. During interview on 9/7/23 at 8:11 a.m., licensed practical nurse (LPN)-A stated the blood sugar monitoring are displayed on the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure an appropriate medical diagnosis for use of scheduled anti-psychotropic medications for 1 of 3 residents (R33) reviewed for unnecessary medications. Findings include: R33's quarterly Minimal Data Set (MDS) dated [DATE], indicated severely impaired cognition (poor ability to understand), no hallucinations or delusions (Seeing a different reality) with diagnoses of medically complex conditions (more than one complicated medical diagnosis,) including Non-Alzheimer dementia (Poor brain and memory function), and transient ischemic attack (Stroke like event). R33 was identified as being on antipsychotics (Medications for preventing psychotic behaviors). R33's Care plan dated 4/5/23 indicated alteration in psychosocial well-being related to memory loss and medical diagnosis of unspecified dementia (Memory loss) without behavioral disturbance (disturbing behaviors), and to monitor for behaviors. R33 became physically aggressive at times,…

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

Based on interview and document review the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, during 1 of 1 quarters (Quarter 2), reviewed for payroll based journal (PBJ). Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705 identified the following dates triggered : 1/1, 1/2, 1/7, 1/8, 1/21, 1/22, 2/5, 3/18, 3/19 for failure to have licensed nurse coverage 24 hours per day and 1/7, 1/8, 1/21, 1/22, 2/5, 2/18, 2/25, 3/5, 3/18, 3/19 for no registered nurse (RN) hours. Daily postings on the above-mentioned dates identified licensed nursing staff including registered nurses had worked and therefore the data submitted in the PBJ to CMS was inaccurate. Interview on 9/7/23 at 9:26 a.m., staffing coordinator (SC) identified this was the first time (Quarter 2) the facility submitted information rather than the corporate office and there was a struggle with obtaining the necessary information from the staffing agencies. SC was not familiar or experienced with this process. Interview on 9/7/23 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.