Mission Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure adaptive equipment was provided for 1 of 2 residents (R3) reviewed for safety while smoking. Findings include: R3's significant change Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included chronic obstructive pulmonary disease, schizophrenia, and R3 was cognitively intact. R3's Smoking assessment dated [DATE], indicated R3 used 6-10 cigarettes a day and did not have a preference on time of day he liked to smoke. R3 was assessed to need a smoking apron for adaptive equipment while smoking. Further, interdisciplinary team reviewed and determined R3 had a modified smoking plan, wears an apron for safety and had not been observed falling asleep with current assessment. Review of facility document titled Mission Nursing Home Resident Leveling and Smoke Program, undated, identified R3 as a smoker, on a modified smoking program, and required a smoking apron. On 4/8/25 at approximately 10:00 a.m., R3 was observed…

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 record review, the facility failed to develop a plan that defined measurable goals and create a system to collect feedback from resident and resident representatives. This had the potential to affect all 56 residents in the facility. Findings Include: During entrance interview on 3/10/25 at 12:54 p.m., a request for a copy of the Quality Assurance and Performance Improvement (QAPI) plan was made to the director of nursing (DON). On 3/13/25 at 1:37 p.m., another request was made for a copy of the QAPI plan. On 3/13/25 at 2:25 p.m., the facility's QAPI program policy was provided. On 3/12/25 at 2:44 p.m., the director of nursing (DON) provided meeting minutes for the last four quarters, but failed to provide an overall plan. QAPI meeting minutes included attendees, agenda, and data related to focuses such as infections, wounds, medication errors, admission/discharges, and weight changes. The document lacked evidence of target goals for sustainability. The document failed to provided evidence that resident and resident representative feedback was obtained 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 observation, interview and document review the facility failed to ensure a thorough smoking assessment was completed on residents who wished to smoke for 5 of 5 residents (R54, R16, R34, R52 and R19) reviewed for smoking. Findings include: An undated facility document titled Mission Nursing Home Resident leveling and Smoking program identified R54, R16, R34, R52 and R19 as current smokers. R54's admission minimum data set (MDS) dated [DATE], indicated R54 admitted to the facility on [DATE] and had the following diagnoses: Stroke, Non-traumatic brain dysfunction, traumatic brain dysfunction, progressive neurological conditions, and traumatic spinal cord dysfunction. The MDS further indicated R54 was cognitively intact and identified R54 as a current tobacco user. R54's face sheet printed 3/12/25, identified R54 as a current daily smoker. R54's care plan with a last review/revision date of 3/10/25, indicated R54 was an independent smoker, had a goal of remaining safe while smoking and would be reassessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a level II pre-admission screen and resident review (PASSAR) was completed prior to admission for 1 of 1 residents (R54) reviewed who required a level II PASSAR screening for mental illness. Findings include: R54 quarterly minimum data set (MDS) dated [DATE], indicated R54 was cognitively intact, and had experienced feeling down, hopeless or depressed, had trouble falling asleep or staying asleep, felt tired or had little energy, and had difficulty concentrating on things at least half or more days in the two weeks prior to the assessment. R54's face sheet printed 3/12/25, indicated an admission date of 11/26/25, identified R54 as a veteran and listed diagnoses to include major depressive disorder, anxiety disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder and opioid dependency. R54's Minnesota Senior linkage Line preadmission screening results dated 11/25/24, indicated R54 met the requirements for a mental…

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 infection control program included symptom tracking and ongoing analysis of trending of resident infections to prevent the spread of infections. This deficient practice had the potential to affect all 58 residents in the facility. Findings include: The facility's infection control logs were reviewed for March and April 2024. The logs identified tracking records of residents with infections, cultures, and treatments. However, the facility lacked documentation of analysis and/or trending of patterns identified. The facility utilized a form titled infection control log which had sections for each of the following items: identifying location, date, the patient, admission date, room number, unit, type, site and date of onset of infection, cultures, organisms, antibiotic resistance. Additionally, whether an antibiotic was started, infection definition (type of), classification section to select community or healthcare acquired infections, date resolved and if the resident was isolated or not. Furthermore, the form…

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

Based on interview and document review the facility failed to implement a process for antibiotic stewardship to determine appropriate indications, dosage, duration, symptoms, analysis of trends and efficacy of antibiotic use. This had the potential to affect any of the 58 residents in the facility. Findings include: The facility's infection control logs were reviewed for March and April of 2024. The logs identified tracking records of residents with infections, cultures, and antibiotic treatments. However, the facility lacked documentation of analysis, trending of patterns identified or efficacy of antibiotics used. The facility utilized a form titled infection control log which had sections for each of the following items: identifying location, date, the patient, admission date, room number, unit, type, site and date of onset of infection, cultures, organisms, antibiotic resistance. Additionally, whether an antibiotic was started, infection definition (type of), classification section to select community or healthcare acquired infections, date resolved and if the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R19) reviewed for dignity. Findings include: R19's admission minimum data set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS-cognitive test) score of 15/15 indicating cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included but were not limited to hemiplegia (weakness or paralysis of one side of the body), bipolar disease (a mental health condition that causes mood swings), and hypertension (high blood pressure). R19's care plan dated 2/14/24 indicated R19's ability to perform activities of daily living (ADL's) had deteriorated related to a diagnosis of hemiplegia and required extensive staff assistance of one to two staff for toileting, dressing, bathing, grooming and bed mobility. Total dependence with Hoyer lift (a device designed 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 record review the facility failed to ensure the resident received unopened mail for 1 of 2 residents reviewed for their right to receive communication with privacy. Findings include: R55's admission minimum data set (MDS) dated [DATE] indicated a brief interview for mental status (BIMS) was 14 and R55 was cognitively intact. R55's MDS listed the following diagnoses: congestive heart failure (heart does not pump blood efficiently), Diabetes Mellitus, depression, and post traumatic stress disorder (PTSD). On 5/30/24 at 10:29 a.m., resident council met and R15 stated sometimes social services (SS)-A went through their mail for contraband. On 5/30/24 at 11:03 a.m., SS-A stated they were responsible for sorting and delivering the mail on the weekdays. SS-A stated they delivered the mail unopened but had performed searches of the mail for suspected illicit drugs or alcohol, with the consent of the resident. On 5/30/24 at 4:04 p.m., the administrator stated they were unaware SS-A had been going…

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 advanced directives were accurately documented in the resident's electronic medical record (EMR) under physician orders for 1 of 1 residents (R109) reviewed for accurate code status. Findings include: R109's hospital discharge orders dated [DATE], identified the need for postoperative care and an order for full code (the initiation of cardiopulmonary resuscitation (CPR) in the absence of a pulse). R109's facility signed physician order report dated [DATE], identified an order dated [DATE] for full code. R109's EMR banner identified a code status of do not resuscitate (DNR). R109's facility face sheet dated [DATE] identified an admission date of [DATE], diagnoses of cholecystectomy (a procedure to remove the gallbladder) aftercare, abscesses (confined pockets of pus caused by infection) of the liver and peritoneum (the tissue that lines the abdominal wall and pelvic cavity). The face sheet identified R109's code status as DNR. R109's facility…

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 resident rooms were kept clean and in good condition for 1 of 2 residents (R36) reviewed for environment. Findings include: R36's quarterly minimum data set (MDS) dated [DATE] indicated a brief interview for mental status (BIMS) of 9, moderately cognitively impaired, and diagnoses included: heart failure (heart not pumping blood efficiently), hypertension (HTN), and hemiparesis (inability to move part of the body). On 5/28/24 at 12:51 p.m., R36's room had large amount of what resembled brown ground meat across the floor starting from approximately 2 feet to the left of the bed across the main walkway of the room and under the table across from the resident's bed about 2 feet into the room's threshold, spanning approximately 3 feet across the floor. There were straw wrappers and other paper debris on the floor. The resident was in bed resting. On 5/28/24 at 4:52 p.m., the resident's family member (O)-G stated they had recently come 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 a written notification of transfer was sent to the office of the Ombudsman for long term care for 1 of 2 residents (R44) reviewed for hospitalization. Findings include: R44's undated face sheet listed the following diagnoses: heart failure, arthritis, pain, cellulitis (infection of the cell), pleural effusions (collection of fluid, air, pus, or blood between the lining of the lung and the lung itself, causes difficulty breathing), atrial fibrillation (top chambers of the heart beat erratically), lymphedema (collection of fluid in the extremities), chronic obstructive pulmonary disease (COPD- lung disease that makes it difficult to breath), chronic kidney disease-stage 4 (CKD-end stage kidney disease), atherosclerotic heart disease, prosthetic heart valve, pacemaker, obstructive sleep apnea (spells of absent breathing when sleeping), transient ischemic attack (TIA-brief stroke like event), depression, shortness of breath, and dizziness. R44'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 record review the facility failed to accurately implement physician's orders for 1 of 1 resident (R44) reviewed for hospitalizations. Findings include: R44's admission minimum data set (MDS) dated [DATE] indicated the brief interview for mental status (BIMS) of 15/15, cognitively intact. R44's undated face sheet listed the following diagnoses: heart failure, arthritis, pain, cellulitis (infection of the cell), pleural effusions (collection of fluid, air, pus, or blood between the lining of the lung and the lung itself, causes difficulty breathing), atrial fibrillation (top chambers of the heart beat erratically), lymphedema (collection of fluid in the extremities), chronic obstructive pulmonary disease (COPD- lung disease that makes it difficult to breath), chronic kidney disease-stage 4 (CKD-end stage kidney disease), atherosclerotic heart disease, prosthetic heart valve, pacemaker, obstructive sleep apnea (spells of absent breathing when sleeping), transient ischemic attack (TIA-brief…

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 prevent an avoidable pressure injury related to improper placement and use of a mechanical lift sling for 1 of 1 residents (R19) reviewed for pressure injuries. This deficient practice resulted in actual harm for R19 who developed pressure and shearing related injury to his groin, thighs, and buttocks. Findings include: R19's admission minimum data set (MDS) dated [DATE], showed R19 had a brief interview for mental status (BIMS) score of 15/15 indicating cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included but were not limited to hemiplegia (weakness or paralysis of one side of the body), bipolar disease (a mental health condition that causes mood swings), and hypertension (high blood pressure). R19's care plan dated 2/14/24 indicated performance of activities of daily living (ADL's) had deteriorated related 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 Surveyor: [NAME], [NAME] M. Based on observation, interview, and document review, the facility failed to perform mechanical lift and lift sling assessments for 1 of 1 residents (R19) to ensure appropriate use and proper size. Further the facility failed to adequately train staff on manufacturers guidelines for use of mechanical lift. This deficient practice had the potential to effect all residents requiring assist with a mechanical lift. Findings include: R19's admission minimum data set (MDS) dated [DATE], showed R19 had a brief interview for mental status (BIMS) score of 15/15, cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included hemiplegia (weakness or paralysis of one side of the body) and muscle weakness. R19's care plan dated 2/14/24 indicated R19's ability to perform activities of daily living (ADL's) had deteriorated related to a diagnosis of hemiplegia and required extensive…

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 of weight was completed as directed for 1 of 3 residents (R45) reviewed for nutrition. Findings include: R45's quarterly minimum data set (MDS) dated [DATE], indicated R45 was cognitively intact, had poor appetite or overeating, and was independent with eating. The MDS also included diagnoses of hypertension (high blood pressure), hyperlipidemia (too much fat in a patient's blood), and paraplegia (partial or complete paralysis of the lower half of the body. Additionally, the MDS indicated R45 was at risk for pressure ulcers and had at least one stage two, partial thickness pressure ulcer, at least one stage three, full thickness pressure ulcer, one stage four, full thickness pressure ulcer with exposed bone, tendon, or muscle, and at least one unstageable pressure ulcer. R45's care plan dated 1/24/24 indicated R45 had a nutritional risk due to diagnoses of paraplegia, hypertension and hyperlipidemia, 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.

Based on observation, interview and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 2 residents (R42) reviewed for dialysis. Findings include: R42's Resident Face Sheet dated 5/31/24, included diagnosis of end stage renal disease (ESDR), hypotension of hemodialysis (low blood pressure), anemia in chronic kidney disease (low red blood cells), and dependence on renal dialysis. R42's physician order report dated 5/31/24, included an order to prepare a PRN dose of midodrine 10 mg (a medication to treat low blood pressure) to send with resident to dialysis Tuesday, Thursday and Saturday. Physician order report failed to include orders to monitor AV fistula for a thrill (a specific feeling over the dialysis graft) and a bruit (a whooshing sound heard with a stethoscope over the dialysis graft site) daily. R42's treatments administration history for May 2024 printed 5/30/24, included an order to avoid taking blood pressure or lab draws on left arm and to remind/encourage R42 to keep the pressure dressing intact after dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a clinical rationale for the extended use of an as needed (PRN) antianxiety medication (Ativan) beyond 14 days was documented for 1 of 1 resident (R25) reviewed for hospice services. Findings include: R25's quarterly minimum data set (MDS) dated [DATE], indicated R25 had a brief interview for mental status (BIMS) of 11 and was a substantial to maximum assist for dressing and cares and dependent for bathing. R25's MDS indicated diagnoses of hypertension (high blood pressure), diabetes mellitus, dementia (loss of cognitive functioning), hemiparesis (loss of ability to move part of one's body) and anxiety disorder. R25's current physician orders signed 5/1/24, indicated an order for lorazepam (Ativan) 1mg by mouth (PO) every 2 hours as needed (PRN). The start date was 3/13/24 and end date of 9/13/24. R25's medical record lacked clinical rationale for the extended use beyond 14 days. R25's electronic medical record (EMAR) reviewed 5/31/24, 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 1 of 5 residents (R35) received a pneumococcal vaccine offered by the facility. Findings include: R35's undated face sheet indicated R35 was [AGE] years of age, admitted to the facility on [DATE], and had diagnoses of current smoker, traumatic subdural hemorrhage without loss of consciousness (stroke related to bleeding in the brain), dysphagia (difficulty swallowing), diabetes mellitus, atrial fibrillation (top chambers of the heart beat erratically), congestive heart failure (heart does not beat efficiently), and depression. R35's current physician orders reviewed 5/31/24, indicated a physician's order on 2/29/24 which read may receive pneumococcal vaccinations if indicated. R35's progress note dated 3/15/24, indicated R35 had received education and given consent upon admission to receive a dose of the pneumococcal conjugate vaccine (PCV) 15 or PCV-20. R35's vaccination record dated 5/29/24, lacked evidence a pneumococcal vaccination 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 ensure confidentiality of personal records for one of one resident (R1) reviewed. The facility gave R1's medical information to his probation officer and the electric health monitor case manager. Findings Include: R1's Face sheet printed on 4/24/24 indicated R1 was admitted to the facility on [DATE]. Diagnoses included alcoholic gastric without bleeding, alcohol induced acute pancreatitis, and alcohol dependence. R1's progress note dated 2/16/24 indicated R1 was admitted to the facility for alcohol induced gastritis, esophagitis, and metabolic acidosis. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 had a score of 15 which meant R1 was cognitively intact. R1's progress note dated 3/14/24 indicated facility staff found empty bottles of alcohol in R1's room. The progress note indicated R1 admitted to drinking two pints of alcohol in the last eight days. R1's progress note dated 3/18/24 indicated R1 had anxiety, nausea,…

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 appropriate personal protective equipment (PPE) for source control was worn by all staff, per the Centers for Disease Control (CDC) grid, directing everyone should mask in communal areas of the facility while in COVID-19 outbreak status. This had the opportunity to affect all residents and visitors. Findings include: The CDC PPE grid directs source control is recommended by those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 (COVID-19) or other outbreak of respiratory infection; universal use of source control could be discontinued as mitigation measure once the outbreak is over; no new cases of COVID-19 have been identified for 14 days. On 12/12/23 at 9:27 a.m., at the entrance of the facility, a sign indicated the facility had three cases of COVID in the building. On 12/12/23 at 9:27 a.m., a facility document posted on the wall in the entrance of the facility dated 4/17/23 directed masks were no longer required while in the building. On 12/12/23 at 9:27 a.m., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide a timely influenza immunization as recommended by the Centers for Disease Control (CDC) for 1 of 5 residents (R2) residents reviewed for immunizations. Findings include: The CDC recommends before an outbreak occurs the influenza vaccination should be provided routinely to all residents and healthcare personnel of long-term care facilities. If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged =65 years, the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. R2's admission Minimum Data Set (MDS) dated [DATE] indicated he had a medial diagnosis of Parkinson's Disease. The MDS assessment lacked documentation of influenza immunization. R2's Influenza Consent form signed by R2 on 10/18/23 indicated he wished to receive the influenza immunization. R2'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.