The Villas At Robbinsdale

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review the facility failed to provide wound care as ordered for 1 of 3 residents (R2) reviewed for wound care. Additionally, the facility failed to ensure R2's care plan indicated wound care and pouch changes for the fistula. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had a surgical wound, and required non-surgical dressings. R2's diagnoses list printed 2/25/25, included fistula of intestine. R2's hospital discharge orders dated 2/5/25, indicated the following: Wound care management 1. Remove pouch with adhesive spray. 2. Cleanse surrounding skin with Vashe [wound cleaner]and pat dry. 3. Use 3M Advanced Care Wand to raw skin. Let dry one minute. 4. Offer Lidocaine spray (prevents pain caused by some procedures). 5. Measure and cut out opening of Convatec Eakin Fistula Manager ( (square) or Coloplast Post op pouch 18681/18691 (round)- (pouches designed to protect skin and contain drainage from wounds and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review the facility failed to conduct appropriate hand hygiene during wound care for 1 of 3 residents (R2) reviewed for wound care. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had a surgical wound, and required non-surgical dressings. R2's diagnoses list printed 2/25/25, included fistula of intestine. On 2/26/25 at 11:04 a.m., R2's wound care was observed. Licensed practical nurse (LPN)-A washed his hands with soap and water prior to performing wound care. LPN-A donned gloves, opened R2's fistula collection bag that contained stool, removed a soiled dressing saturated with stool from inside bag, placed the soiled dressing in the garbage, and drained the bag into a plastic receptacle to measure R2's stool output. LPN-A doffed his gloves, and donned clean gloves. LPN-A did not perform hand hygiene between glove changes. LPN-A used a Sani wipe to clean stool from R2's legs, discarded the Sani wipe in 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 record review the facility failed to ensure 1 of 1 residents (R1) reviewed for skin alterations had weekly skin observations completed, in addition to informing the interdisciplinary team of R1's skin breakdown. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated R1 had peripheral vascular disease, diabetes with neuropathy (lack of sensation caused by nerve damage) and was cognitively intact. The MDS further indicated R1 was dependent for toileting, hygiene, and required maximum assistance by 2 staff for mobility and transfers. R1's Care Plan dated 7/08/24, indicated R1 had the potential for alteration in skin integrity. Staff were to monitor skin integrity daily during cares and perform weekly skin inspections and provide treatment to open areas per physician order. R1's Risk vs Benefits form dated 8/12/24, indicated staff were to ensure pressure offloading and position changing and incontinence care occurred related to the concern for skin…

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 1 of 3 ice dispensing machines were clean and free of excess mineral build up and cleaned on a regular schedule. This had potential to affect all residents of the nursing home, staff, and visitors who consumed food from the main production kitchen and/or ice and water from the fourth floor dining room ice machine. Findings include: During observation on 7/25/24 at 9:28 a.m., the fourth floor dining room ice and water dispenser had white, speckled, crust residue on the inside of the dispenser chutes, the drip tray, and other surfaces. During interview on 7/25/24 at 11:27 a.m., maintenance director (DOM) stated the third floor water and ice dispenser in the dining room was out of commission, and they worked on the fourth floor water and ice machine last night because the light came on which indicated it was time to complete maintenance, so DOM ordered the chemical cleaners and sanitizer to complete the cleaning. DOM stated the facility's system reminded them every month or every other month to check if…

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 timely assistance with incontinence care when requested to promote dignity for 1 of 1 residents (R41) reviewed for dignity. Findings include: R41's quarterly Minimum Data Set, dated [DATE], indicated R41 was cognitively intact, had diagnoses of kidney failure, anxiety, and depression, was frequently incontinent of urine and bowel, and fully dependent on staff for toileting needs. R41 was able to understand and was easily understood. R41's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 3/18/24, identified R41 as incontinent of bowel and bladder, dependent on staff for toileting, did not transfer to the toilet, and wore a brief on check and change due to mobility. R41 was at risk for skin breakdown. R41's care plan dated 4/11/24, included R41 was incontinent of bladder, used disposable briefs, and instructed staff to offer R41 assistance to check and change upon rising, before and after meals, 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 observation, interview, and document review, the facility failed to comprehensively re-assess for ability or safety, document resident education regarding risks, and care plan the self-administration of medications for 1 of 1 resident (R41) known to obtain their own medication from outside sources, who was observed to have such medications at bedside. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], included R41 was cognitively intact, had diagnoses of dysphasia (difficulty swallowing), malnutrition, attention deficit hyperactivity disorder, depression, and anxiety, and required set-up or clean-up for eating. R41's care plan dated 4/10/24, included R41 completed a risk/benefit form due to their desire to continue and inappropriate diet and unwillingness to elevate the head of the bed to prevent aspiration. A care plan intervention dated 12/6/22, indicated R41 required assistance to eat but refused. R41's MHM Self Adminsitration of Medication Evaluation dated 10/2/23, indicated R41…

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 comprehensively assess and monitor non-pressure related skin conditions for 1 of 2 residents (R40) reviewed for skin concerns, and failed to monitor resident weights for 1 of 1 residents (R40) reviewed who took a diuretic and had a history of weight fluctuations. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 was cognitively impaired, had a diagnoses of alcohol use disorder, depression, and cellulitis, was incontinent of bowel and bladder, and required supervision for walking and toileting. R40's hospital discharge note dated 6/11/24, identified R40 was admitted to the hospital through the emergency department on 5/31/24, with severe dehydration, nausea, vomiting, diarrhea, shortness of breath, low blood pressure and high heart rate. Their weight at hospital admission on [DATE] was approximately 188.5 pounds. R40's hospital nutrition assessment date 6/5/24, included R40 weighed approximately 188.5…

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, interviews and document review, the facility failed to ensure that residents received proper follow-up recommendation for hearing assistive devices to maintain hearing abilities for 1 of 1 residents (R12) reviewed for hearing services. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition, had no rejections of care or rejections of evaluation of care, and had diagnoses of Alzheimer's dementia, anxiety, and high blood pressure. R12's Care Area Assessment (CAA) for communication dated 7/21/23, identified R12 appeared hard of hearing but did not wear hearing aids. The CAA indicated R12 was at risk for mixed messages. A hearing and vision assessment dated [DATE], identified R12 had adequate hearing and did not wear hearing aids. R12's care plan lacked documentation of communication needs. An audiology (hearing) provider progress note dated 2/12/24, identified an order for a medical consult to obtain medical clearance for hearing aids. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were disposed of after expiration date and were properly stored, labeled, and dated when the original packaging was opened. This deficient practice had the potential to affect all 70 residents who resided in the facility. Findings include: Upon observation on 1/30/24 at 10:22 a.m. the refrigerator in the facility's main kitchen. The following items were expired and still in the refrigerator: -one gallon size container of potato salad with a manufacture use by date of 12/8/23, -one opened half-gallon of buttermilk with a manufacture use by date of 12/23/23. - A block of cream cheese in a cardboard box with the inner foil torn. Approximately 1/3 of the cream cheese had been used and mold was found covering the cheese where the inner foil had been opened, the manufacture use by date was 11/4/23. The following items were opened without any dates: -Three one-gallon size salad dressings - One plastic container…

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 the food a residents brought in from the outside was dated and labeled the transitional care unit. This had the potential to affect all 20 residents who resided on that floor. In addition, the facility was unable to provide documentation that the residents communal refrigerator temperatures were being monitored. Findings include: Upon observation on 1/30/24 at 12:46 p.m. the resident floor refrigerator was found to have six plastic grocery bags that were tied bags with deli-style boxes of food inside, none of these bags were labeled with a name or a date. There was a bag of rotisserie chicken in the manufacturers bag that stated keep frozen in the refrigerator with thawed meat unlabeled with a name or date. There was a package of opened half-eaten [NAME] jack cheese slices with no name, it had a use by date of 10/12/23. In addition, there was an opened jar of salsa with mold inside with a use by date of 9/21/22. The refrigerator…

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 personal hygiene to 3 of 4 residents (R2, R6, and R7) dependent on staff for activities of daily living (ADL's). The residents did not receive timely showers or weekly skin assessments. Findings include: R2's care plan dated 8/9/22 indicated R2 required the assistance of one staff member to assist with bathing. The care plan did not indicate how often bathing was to be performed. R2's physician order sheet dated 5/22/23 indicated R2 was to receive a weekly shower. 1. Ensure shower/bath was completed, chart refusals. 2. Complete weekly skin inspection. 3. Nurse to ensure aide trims fingernails and toenails. 4. Notify supervisor or nurse manager of any skin alterations. R2's weekly skin inspection reports reviewed from 11/1/23 - 1/31/24 indicated R2 received weekly skin inspections on 11/9/23, 11/27/23, and 1/15/24. R2's nursing progress notes reviewed from 11/1/23 - 1/31/24 did not indicate R2 had refused any weekly showers or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 2 of 4 residents (R6 and R7) received daily weights as ordered to monitor for heart failure and unexplained weight loss. Findings include: R6's admission MDS dated [DATE] indicated R6 had a BIMs score of 15 indicating he was cognitively intact. R6's MDS did not indicate how R6 was to bathe or shower. R6's pertinent diagnoses were left femur (thigh bone) fracture and chronic respiratory failure with hypoxia (low level of oxygen in the body). R6 physician order dated 1/26/24 indicate R7's parameters for Lasix 20 milligram (mg) by mouth everyday prn (as needed); give medication if patient has gained 2 lbs. in 1 day or 5 lbs. in 1 week for significant leg edema; diagnosis diastolic heart failure. R6's Weight summary dated 1/18/24 - 1/31/24 indicated: -1/28/24 his weight was 153.4 and on 1/31/24 his weight was 146.8 lbs. R6's progress notes dated 1/13/24 - 1/31/24 indicated: -1/18/24 at 6:00 a.m. R6 refused to be weighed, stating is so early, do…

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 a medical record that was accurately documented for 1 of 1 resident (R1), when Registered Nurse (RN)-A documented a completed treatment that had not been completed. Findings include: R1's quarter Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 15 indicating R1 was cognitively intact. R1 was dependent with toileting, showering, and lower body dressing requiring two staff members. R1 required maximum assistance with rolling in bed and hygiene. R1's diagnoses were calculus in bladder (bladder stones), moderate protein calorie deficiency and chronic pain. R1's physician order sheet dated 12/5/23 indicated wound care to left great toe every a.m. shift. 1. Clean wound with moist 4x4 gauze. 2. Paint wound with iodine swab. 3. Cover with gauze and tape. R1's electronic treatment administration record printed 1/31/24 at 11:34 indicated registered nurse (RN)-A had completed the wound…

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 Policy titled Infection Prevention and Control- Contact Precautions dated 7/31/23 identifies contact precautions are intended to prevent transmission of the infectious agents, including epidemiologically important microorganisms, spread by direct or indirect contact with the resident or the residents environment. In addition to Standard Precautions, Contact Precautions will be used to prevent the healthcare acquired spread of organisms that can be transmitted by direct or indirect resident contact (hand or skin-toskin contact that occurs when performing resident care) or by indirect contact (touching) with environmental surfaces of contained resident care equipment. Contact Precautions may be considered for residents who have: 1. Infections (including Multi-Drug Resistant Organisms (MDROs)) 3. Uncontained wound drainage from an infected wound 5. Other epidemiologically significant organisms as determined by the facility's infection preventionist (IP) and the Medical Director. Healthcare personnel caring 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 thoroughly investigate potential drug diversion for 1 of 1 resident (R418) reviewed for misappropriation of resident property. Findings include: R418's significant change Minimum Data Set (MDS) 12/2/22, indicated R418 had severe cognitive impairment with delusional thinking and hallucinations and diagnoses of respiratory failure and dementia with behavioral disturbances. Furthermore, R418's MDS indicated R418 required assistance of one for transfer and ambulation in room and was on hospice. R418's hospice pharmacy delivery slip dated 12/30/22, at 4:53 p.m. indicated 120 oxycodone 10 milligram (mg) tablets (narcotic pain medication), 60 lorazepam 1 mg tablets (anti-anxiety medication), quetiapine 25 mg tablets (antipsychotic medication) and budesonide nebulizer (medication to help with breathing) had been delivered. R418's progress note dated 12/31/22 at 3:09 p.m., indicated R418 was found taking medication in his room. Two medication cards of oxycodone, 2 cards of lorazepam, quetiapine and some nebulizers were removed…

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 that baseline care plans were developed and implemented within 48 hours of admission for one (R367) resident reviewed for care plans. Findings include: During an observation on 6/5/23 at 10:05 a.m., R367 was laying in her bed sleeping with meal tray on bedside table. R367 with a vacuum assisted closure of wound (wound vac) involving a special dressing connected to a pump that gently draws fluid and infection from a wound using negative pressure. This was attached to R367's left foot. Review of R367's clinical record revealed R367 admitted to the facility on [DATE]. A baseline care plan downloaded at 6/5/23 at 11:34 a.m., showed the only focus of care as Potential alteration in nutrition r/t wt loss, therapeutic diet, wound which was initiated on 6/2/23. A baseline care plan containing the minimum healthcare information necessary to provide proper care such as initial goals, physician orders, therapy services, and social services for R367 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 comprehensive and individualized care plan was developed and implemented for 1 of 1 resident (R27) reviewed for dialysis. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. R27's diagnoses included nephritic syndrome with diffuse mesangiocapillary glomerulonephritis (an injury resulting in inflammation in the kidneys) end stage renal (kidney) disease with dependency on renal dialysis, and unspecified nephritic syndrome with morphologic changes (resulting in inflammation in the kidneys). R27's Treatment Details Report dated 5/31/23, indicated R27's dialysis access was a central venous catheter (CVC). R27's care plan dated 5/3/23, indicated R27 received kidney dialysis related to renal failure. Interventions included not drawing blood or taking a blood pressure from the arm with a graft although R27 did not have a graft. R27's care plan also lacked indication R27's 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 observation, interview and document review the facility failed to ensure provider order was present for treatment of a non-pressure related wound care for 1 of 1 (R367) reviewed for wound vac. Findings include: R367 was admitted to facility on 6/1/23. Diagnosis listed on Interagency Assessment & Transfer Form dated 6/1/23 at 12:18 p.m., include wound of left foot, wound dehiscence, sepsis, diabetic infection of left foot, osteomyelitis of ankle and foot, diabetes. The transfer form indicated Wound Therapy as, Wound VAC #1 Left Foot (involving a special dressing connected to a pump that gently draws fluid and infection from a wound using negative pressure) with placement date of 5/22/23. R367's Interagency Transfer Orders printed on 6/1/23 at 10:54 a.m., state Wound care Comments: Wound care instructions: wound vac set at 125mmHg of continuous suction Change three times weekly by skilled nursing. Pad the tubing appropriately off of the skin. Secure with Gauze, kerlix, ace wrap. R367's 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 assistive devices to maintain hearing abilities and vision were provided for 1 of 1 resident (R34) reviewed for hearing and vision devices. Findings include: R419's significant change minimum data set (MDS) dated [DATE], indicated resident was cognitively intact. R419's care plan dated 2/10/23, indicated resident had impaired visual function and wore glasses as desired. A patient encounter note from a doctor of optometry (OD) dated 1/31/2023 indicated, With significant refractive differences between eyes, patient is having difficulty with vision. Recommended sataract surgery of the left eye or a new pair of glasses. During observation and interview on 6/5/23 at 9:57 a.m., R419 wore glasses. R419 stated they wanted their cataracts taken care of and offered to pay full price or would pay for new glasses. During an interview on 6/7/23 at 9:19 a.m., R419 confirmed they had spoken with the facility to check in on the cataract surgery.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement a physical therapy (PT) ordered restorative nursing program to prevent potential decrease in range of motion (ROM) for 2 of 3 residents (R19,R57) reviewed for restorative nursing programs. Findings include: R57's significant change Minimum Data Set, dated [DATE], indicated R57 had adequate hearing and clear speech and could usually understand and be understood by others, however lacked documentation of a cognitive assessment. It included diagnoses of stroke with paralysis on one side of his body requiring extensive assistance of two staff for bed mobility, transfers, and toilet use, and he had limited ROM in both upper and lower extremities on one side (left). In addition, he did not have therapy services nor were restorative nursing programs performed in the preceding seven days. R57's Activities of Daily Living (ADL), Cognition, and ADL Functional/Rehabilitation Potential care area assessments were not triggered. R57's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to consistently implement identified interventions to reduce the risk of falls for 1 of 1 residents (R57) reviewed for falls. R57's significant change Minimum Data Set, dated [DATE], indicated R57 had adequate hearing and clear speech and could usually understand and be understood by others, however lacked documentation of a cognitive assessment or fall history on admission and inditated he had not falled since admission. It included diagnoses of stroke with paralysis and limited range of motion on one side of his body (left) requiring extensive assistance of two staff for bed mobility, transfers, and toilet use. R57 was frequently incontinent of bowel and not on a toileting program. R57's falls Care Area Assessment (CAA) dated 5/15/23, included he was at risk for falls due to a history of stroke, impaired balance/mobility, and cognition, and identified he was mostly bed bound, required a mechanical lift for transfers, and included staff…

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 comprehensive assess, and create and implement interventions for ongoing, undesired weight loss for 1 of 1 resident (R12) reviewed for significant weight loss. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 had mild cognitive deficits and was independent for eating and did not have a swallowing disorder. R12's diagnoses included, Alzheimer's disease, muscle weakness, dysphagia (difficulty swallowing), muscle wasting. R12's Care Area Assessment (CAA) dated 1/25/23, indicated R12 triggered for activities of daily living (ADLs), psychosocial well-being, mood, falls, nutrition, pressure ulcers, and psychotropic drug use. R12's care plan dated 12/31/22, indicated R12 had a nutritional or potential nutritional problem related to a mechanical soft diet, weight loss and the progression of dementia and that weight loss comfort care was ordered. Interventions indicated to allow choices at mealtime, menu…

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 alternatives prior to installing a bed rail on the bed, assess the resident for risk of entrapment, and to review risks and benefits of bed rails with the resident or their representative and obtain informed consent for 1 of 1 residents (R46) reviewed who had rails on their beds. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact, required extensive assist of two staff for bed mobility, transfer, and toilet use, and had diagnoses of diabetes and vascular disease (a disease which causes narrowing of the blood vessels). The MDS indicated bed rails were not used. R46's care plan updated 5/29/23, did not include the use of bilateral bedrails. During observation and interview on 6/5/23 at 9:44 a.m., R46 was lying in bed with the head of the bed elevated, and one-half sized bedrails affixed to each side of the upper half of the bed. R46 stated he used them to help him turn over.…

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 dental needs were comprehensively assessed and appropriately acted upon (i.e., referred to a dental provider) for 1 of 1 resident (R23) reviewed who voiced dental concerns. Findings include: R23's face sheet dated 6/8/23, indicated diagnoses of dysphagia. Payer information listed primary payer as Medicaid. R23's significant change Minimum Data Set, dated [DATE], indicated no concerns with oral/dental status. Broken or loosely fitting full or partial denture an no natural teeth was not selected. Exam notes from Health Drive Dental Group with exam date of 3/23/22, indicated R23 lost lower denture and upper denture had an ill fit. The Doctor of Dental Surgery recommended new dentures or modify upper denture by a reline. Pt would like to eat better and have a smile again. During observation and interview on 6/5/23 at 11:40 a.m., R23 did not have visible natural teeth nor dentures in. R23 stated they would like dentures and had 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 interview and document review, the facility failed to provide rehabilitative services as ordered for 1 of 2 residents (R57) reviewed for therapy services. Findings include: R57's significant change Minimum Data Set, dated [DATE], indicated R57 had adequate hearing and clear speech and could usually understand and be understood by others, however lacked documentation of a cognitive assessment. It included diagnoses of stroke with paralysis on one side of his body requiring extensive assistance of two staff for bed mobility, transfers, and toilet use, and he had limited range of motion (ROM) in both upper and lower extremities on one (left) side. In addition, he did not have therapy services in the preceding seven days. R57's Activities of Daily Living (ADL), Cognition, and ADL Functional/Rehabilitation Potential care area assessments were not triggered. R57's care plan dated 4/3/23, directed staff to follow physical therapy (PT) and occupational therapy (OT) instructions for functional mobility. R57'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.

Based on observation, interview and document review, the facility failed to ensure proper enhanced barrier precautions were adhered to for 1 of 3 residents reviewed for transmission-based precautions. This had the potential to affect all staff and all 60 residents residing in the facility. Findings include: On 3/29/22, R31 had a positive culture for Klebsiella Pneumoniae, a carbapenem resistant bacteria classified as a multi-drug resistant organism (MDRO) that is highly contagious through contact with human secretions. After the positive culture, the facility placed R31 on enhanced barrier precautions. Enhanced barrier precautions guided staff to don gowns and gloves before coming into contact with their skin or potentially contaminated articles such as bedding or personal items. During observation on 6/5/23 at 2:37 p.m., R31 was sitting in their room on a shower chair. Nursing assistant (NA)-A was in the resident room with gloves but without a gown changing the residents bed linens. A sign was taped to R31's door that indicated R31 was to be on enhanced barrier precautions and all…

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 2 of 5 residents (R59, R56) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC's Pneumococcal Vaccine Timing for Adults dated 3/15/23, identified: -adults 65 years or older who had not previously received a PCV13, PCV15, or PCV20, or had not previously received any pneumococcal vaccine, one dose of PCV20 (pneumococcal conjugate vaccines) should be administered. -adults aged 19-64 years with certain underlying medical conditions (including heart failure) whose previous vaccination history was unknown should receive one dose PCV20. R59's face sheet undated, identified he was [AGE] years old and admitted on [DATE]. R59 had a diagnosis of heart failure and had no allergies to vaccines or contraindications to vaccines listed. R59's medical record lacked evidence a vaccination history was obtained, or a pneumococcal vaccination was offered or received.…

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.