Edenbrook Rochester West

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure food preferences were comprehensively assessed, a physician ordered nutritional supplement was available for administration and further failed to obtain physician ordered daily weights for 1 of 3 residents (R1) with impaired nutrition to help maintain adequate nutritional status that was consistent with the residents nutritional assessment, reviewed for weight loss. Findings include: Nutritional supplement: refers to products that are used to compliment a residents dietary needs (e.g., calorie or nutrient dense drinks .and meal replacement products). R1's order summary dated 2/20/24, identified an order to daily call MD if weight change of 3 pounds in 1 day or greater than 7 pounds in 1 week every day. An additional order dated 6/27/24, for Boost Breeze (a nutritional fruit flavored drink that provides extra calories and protein) every day at HS for additional nutritional support. On 8/27/24, identified to provide ProHeal (a liquid…

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 food temperatures were monitored consistently prior to serving to prevent risk of food born illness. The facility further failed to maintain a clean refrigerator and freezer for food storage. This had the potential to affect all 28 residents residing at the facility. Findings include: During dining/kitchen tour on 10/21/24 at 2:30 p.m., with dietary manager (DM) identified resident refrigerator in the dining room adjacent to the kitchen was to have loose debris laying on the bottom , unknown sticky substance spilled on bottom and on the shelves. In addition, items were not labeled to identify what items belonged to what residents. Observation of the freezer located in the basement of the facility had loose frozen carrots on the bottom, looked like ice buildup on top shelf, and frost around the door. DM reported cleaning the refrigerator and the freezer are shared by nursing and dietary staff. DM revealed there was no cleaning log or schedule to ensure completion. DM further identified they are to be…

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 appropriately assess for broken/missing teeth and difficulty chewing for 1 of 1 (R24) resident. Findings include: R24's 8/27/24, admission Minimum Data Set (MDS) assessment identified her cognition was moderately impaired. R24's diagnosis list identified diagnosis of moderate protein calorie malnutrition, paranoid schizophrenia, dementia, and weakness. R24's oral assessment dated [DATE], indicated R24 had her own teeth and does not wear dentures, has chewing problems and R24 would be a regular diet with thin liquids with a care plan intervention to provide diet as ordered. R24's Nutritional assessment dated [DATE], identified R24 ate independently, was on a regular diet, had no difficulty chewing or swallowing, and would be given a supplement three times daily. The assessment summary identified the current diet order remains appropriate, resident appears to be tolerating diet texture and consistency, and current diet order/oral…

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 an insulin FlexPen was appropriately primed prior to insulin administration for 1 of 2 residents (R14) who received sliding scale (SS) insulin. Findings include: During an observation and interview on 10/22/24 at 4:32 p.m., registered nurse (RN)-A prepared to administer R14's SS insulin dose. R14's blood glucose (BG) reading checked on 10/22/24 at 4:26 p.m. was 264. The physician orders for SS Novolog Aspart insulin (FlexPen) identified the dose to be administered as 8 units. RN-A checked the pen against the MAR, removed the pen cap, dialed the pen to 2 units and depressed the plunger. She then obtained a package containing the needle for the pen, and additional supplies and preceded to R14's room. RN-A performed hand hygiene, applied gloves, wiped the end of the pen with an alcohol pad and attached the needle. She then dialed the pen to 8 units, and prepared to administer the insulin dose. RN-A was interrupted and she and the surveyor exited the room, where RN-A was asked about priming the pen without…

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 utilization of proper personal protective equipment (PPE) with cares for 1 of 2 residents (R8) evaluated for enhanced barrier precautions (EBP). Findings include: R8's quarterly Minimum Data Set, dated [DATE] indicated R8 was cognitively intact with no behaviors, limited range of motion to both upper and lower extremities, frequent incontinence of bowel and bladder, G-tube (tube surgically placed in stomach), and tube feeding (liquid nutrition provided via g-tube) R8's face sheet indicated diagnoses of Parkinson's disease, severe protein-calorie malnutrition, nutritional anemia, and gastrostomy status. R8's orders indicated check tube placement before initiation of formula, medication administration, and flushing tube every 8 hours, flush tube with 20-30 ml of water before and after medications, check and record residuals, Compleat (brand of liquid nutrition) intermittent gravity 2.5 cans/day. ½ can at 9 am, 1 can at 2 pm, and 1 can…

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 waking times were honored for 1 of 1 residents (R2) for choices. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2's did not have cognitive impairment. R2's quarterly psychosocial assessment, dated 11/27/23, identified R2 was Spanish speaking, under section 5. Culturally competent care included a focus of cultural/ethnic preferences: Spanish speaking services when needed. The assessment did not identify interventions to provide choice making activities. R2's care plan dated 10/23/23 did not identify R2's preferences for waking times and daily routines. R2 required assistance from two staff for bed mobility, toileting, and transfers and required assist of one staff for personal hygiene. During an observation and interview on 11/29/23 at 11:48 a.m., R2 was dressed in facility gown lying in bed. R2 explained he did not like to get up early and preferred to get up after lunch. He was not asked upon…

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 a comprehensive assessment for food preferences for 1 of 1 residents (R2) who preferred foods consistent with R2's culture. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2's cognition was intact with diagnoses of diabetes and chronic kidney disease. MDS identified R2 was independent withe eating and did not identify R2's preferences for food choices. R2's care plan dated 10/23/23, did not identify R2's food choices/preferences. R2's Nutritional assessment dated [DATE], indicated R2 had a history of liking most foods with the exception of pork and was satisfied that the food is hot. The assessment did identify R2's food choices pertaining to cultural or individualized preferences to ensure adequate nutritional needs were met. R2's internal medicine visit dated 10/30/23, indicated R2 had nausea which limited his intake, R2 stated it's because he does not like the facility food. R2's progress note…

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 peripherally inserted central catheter (PICC) was appropriately managed based on professional standards of practice and in accordance with physician orders for 1 of 1 resident (R2) reviewed for intravenous (IV) medications. Findings include: R2's hospital after visit summary (AVS) dated 10/4/23 to 10/23/23, R2 underwent placement of a PICC line for two weeks of antibiotics for MSSA (Meticillin-Sensitive Staphylococcus aureus (MSSA)-a blood stream infection) to be discontinued on 10/30/23. After antibiotic therapy PICC line will be removed. R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2's cognition was intact and included diagnoses of MSSA. MDS did not identify any IV medications. R2's order summary dated 11/10/23, included an order for normal saline flush solution 10 milliliter (ml) intravenously as needed (PRN) for PICC patency. The order did not include a scheduled routine and only directed PRN with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to accurately transcribe and administer an intravenous (IV) antibiotic, cefazolin (an antibiotic to treat moderate to severe bacterial infections) for seven days and omitted four doses of an injectable medication, Retacrit (an injectable medication used to treat anemia due to chronic kidney disease to decrease the need for a blood transfusion) per provider orders for 1 of 3 residents (R2) reviewed for medication administration. Findings include: R2's hospital after visit summary (AVS) dated 10/4/23 to 10/23/23, identified R2 was hospitalized for osteomyelitis (inflammation of bone caused by infection) and had a left leg below the knee amputation. R2's developed a fever during hospital course. R2's work up resulted in Meticillin-Sensitive Staphylococcus aureus (MSSA-a blood stream infection caused by a bacteria) from the dialysis line. Dialysis line was removed and R2 was stabilized on IV antibiotics. Because of clinical improvement R2…

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

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed Quarter 3, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 4/22, 4/23, 4/30, 5/2, 5/4, 5/6, 5/7, 5/8, 5/10,5/11, 5/13, 5/14,5/21, 6/3, 6/4, 6/18,6/19, 6/24, and 6/25. for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules identified the facility had licensed staff identified to have worked. Review of the licensed staff timecards on the above-mentioned dates confirmed licensed nursing staff had worked and therefore the data submitted in the PBJ to CMS was inaccurate. Interview on 10/31/23 at 5:08 p.m., with registered nurse consultant (RNC) who identified the facility had received a report…

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 have a comprehensive infection control surveillance program to include tracking resident illnesses through to resolution and identify when employees would be able to return to work after illness, dependent upon their symptoms. The facility further failed to ensure 1 of 1 discontinued hydrocollator was drained and maintained in a sanitary manner to prevent mold-like buildup and prohibit a potential Legionella source of infection and failed to ensure staff had not stored personal items in 1 of 1 occupational therapy (OT) refridgerator and 1 of 1 family room fridge was maintained in a clean and sanitary manner, and staff food was not stored within. Additionally, the facility failed to ensure 2 of 2 mechanical stand lifts were maintained in a clean manner with washable surfaces. This had the ability to affect all 34 residents. Findings include: SURVEILLANCE Review of the May through October 2023, resident surveillance log identified two infections not treated with antibiotics, were COVID positive and they were noted to be…

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 1 hall (200 wing) multi-resident bathroom ceiling, 1 of 1 dining room tiles and ceiling, 1 of 1 wing (200 wing) shower tile, 1 of 1 resident (R1) room wall, 4 of 4 hallway walls which were scuffed had been painted, 2 of 2 mechanical stand-lifts were maintained to have cleanable surfaces, and 1 of 1 entryway tiles was maintained to promote a safe, sanitary, and homelike environment. Findings include: Observations on 10/31/23 from 11:15 a.m., through 11:45 a.m. of the facility identified in the 200 wing shower room, directly above the wall heater unit, 1 tile was broken and half missing. Directly adjacent to that, a piece of sheet-rock, approximately 6 inches wide by 2 inches tall was missing from the wall. There were numerous spots of missing paint noted. The shower tiles were heavily soiled with a dirt-like substance that may be stained into the tile. On the door sill, numerous rust spots and paint chips were noted, and caulk in was loose and missing from around the edges of the shower. Across…

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 to ensure 1 of 2 shower room wall ties were repaired to prevent potential injury for 14 of 34 residents (R1, R4, R5, R9, R10, R12, R15, R17, R19, R22, R24, R29, R334, and R335) who resided on the 200 wing and used that shower. Findings include: Observations on 10/31/23 from 11:15 a.m., through 11:45 a.m. of the facility identified in the 200 wing shower room, directly above the wall heater unit, 1 tile was broken and half missing. Directly adjacent to that, a piece of sheet-rock, approximately 6 inches wide by 2 inches tall was missing from the wall. Interview on 10/31/23 at 11:20 a.m., with nurse aide (NA)-F in the common-use resident bathroom on the 200 wing identified the ceiling around the exhaust fan was chipped and crack sand some parts were missing from the plaster. Maintenance doesn't fix them. She was unsure if any staff alerted maintenance to the needed repairs. Further interview on 11/1/23 at 11:21 a.m., with NA-F of the 200 wing shower room walls and floor identified she agreed the missing tile…

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.

R185's 10/18/23, admission, Minimum Data Set (MDS) assessment identified R185's cognition was moderately impaired, he had diagnosis of irregular heartbeat, recent stroke, heart failure, and weakness. R185 required staff assistance with toileting, dressing and bed mobility, and transfers. Review of R185's diagnosis list identified additional diagnosis of muscle weakness, lack of coordination, unsteady gait, chronic respiratory failure with low oxygen levels, poor vision. Interview on 10/30/23 at 2:19 p.m., with R185 identified staff do not wash me up or brush my teeth in the morning or at bedtime unless he requests them to. Interview on 10/31/23 at 2:30 p.m., family member (FM)-A reported R185 told her staff do not assist him with personal hygiene. She comes every morning at around 9:00 a.m., and stays until around 3:00 p.m., R185's partial dentures are still in when she arrives at the facility from the night before and have not been cleaned. I know they are not cleaning them because they look terrible, and they are full of food. She always has to brush them when she gets to the…

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

Based on observation, interview, and document review, facility failed to ensure 5 of 5 sampled nurse aids (NA-A, NA-B, NA-C, NA-D, and NA-E) were deemed competent upon hire or yearly thereafter to provide care to residents. Findings include: R185's 10/18/23, admission, Minimum Data Set (MDS) assessment identified R185's cognition was moderately impaired, he had diagnosis of irregular heartbeat, recent stroke, heart failure, and weakness. R185 required staff assistance with toileting, dressing and bed mobility, and transfers. Review of R185's diagnosis list identified additional diagnosis of muscle weakness, lack of coordination, unsteady gait, chronic respiratory failure with low oxygen levels, poor vision. Interview on 10/30/23 at 2:19 p.m., with R185 identified staff do not wash me up or brush my teeth in the morning or at bedtime unless he requests them to. Interview on 10/31/23 at 2:30 p.m., family member (FM)-A reported R185 told her staff do not assist him with personal hygiene. She comes every morning at around 9:00 a.m., and stays until around 3:00 p.m R185's partial…

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 have a method in place for timely removal of discarded medications in 3 of 3 medication containers from the facility. Findings include: Observation of the medication room on 11/1/23 at 3:23 p.m., accompanied by director of nursing (DON) identified 3 large black medication containers with lids. Each container had a label identifying they were able to hold up to 66 pounds. Interview on 11/1/23 at 3:23 p.m., with the DON identified the containers were full of discarded medications and she did not know why they had not been picked up and was uncertain how long they had been there. Interview on 11/1/23 at 4:30 p.m., with the maintnance director identified the facility had previously used Stericycle to pick up destroyed/discarded medication but they currently did not have a contract with them. He stated it has been about 3 years since the last time Stericycle had picked up the black bins and they had been having some difficulty renewing the contract due to missing paper work. Interview on 11/2/23, at 1:14 p.m., with 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 complete a thorough investigation to identify potential diversion for 1 of 1 resident (R134) whose Fentanyl narcotic pain patch was missing. Findings include: Review of 6/6/23, complaint submitted identified that on 6/5/23 at 6 a.m., nursing had discovered R134's fentanyl transdermal patch (medicated skin patch used to treat severe pain) was missing from her skin. Nurse reported that she had searched R134's skin, bedding, bathroom, and room and the fentanyl patch could not be found. The nurse applied a new patch and notified hospice. The report identified that the director of nursing (DON) requested the physician order an alternate medication regimen. The DON was notified that a Minnesota Adult Abuse Reporting Center (MAARC) report was submitted. R134's Face sheet printed 11/2/23, identified R134 was admitted to the facility in February of 2023, and was receiving hospice services while at the facility. R134's 7/5/23, quarterly Minimum Data Set (MDS) assessment identified R134's cognition was severely impaired. She had…

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

Based on interview and record review, the facility failed to appropriately discharge 1 of 1 resident (R136) with known dementia with behaviors. The facility also failed to ensure policies related to discharge and transfers were reviewed yearly for appropriateness and accuracy. Findings include: R136 was admitted for respite (short period of rest and relief) stay at the facility on February 2023 with a diagnosis of Lewy body neurocognitive disorder (a progressive dementia that results from protein deposits in nerve cells of brain affecting movement, thinking skills, mood, memory, and behavior) dementia, heart failure, Parkinson's, hypertension and arthritis. R136's February 2023, medication administration record indicated clonazepam (sedative used for seizures, painic disorder and anxiety) 1 milligram (mg) at night for Parkinsons, Nuplazid (antipsychotic used to treat hallucinations and delusions cause by Parkinson's disease) 34 mg daily, Eliquis (blood thinner) 5 mg twice a day and melatonin (for sleep) 15 mg at night for insomnia. R136's 2/24/23, skilled progress note 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 document review the facility failed to ensure a level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 1 resident who was admitted with a diagnosis of Schizoaffective disorder. Findings include: R18's electronic admission record identified R18 was admitted [DATE], with a diagnosis of Schizoaffective disorder upon admission and dementia. R18's admission Minimum Data Set (MDS) assessment identified that a Pre-admission Screening was completed and that the resident had been evaluated with a Pre-admission Screening (PAS I), dated 3/19/20, and OBRA: dated 3/23/20 on the PAS I, the option was checked which indicated that Senior LinkAge did not complete the screening, it was forwarded to a county/managed care organization for processing. The OBRA indicated that R18 did not have a major mental disorder diagnosis. Interview on 11/01/23 at 9:23 a.m., with Licensed Social Worker, (LSW) identified that the facility reviewed the pre-admission screener and PASARR Level I…

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 oxygen tubing was changed in a timely manner for 1 of 2 residents (R26) reviewed for respiratory care. Findings include: R26's admission Record identified R26 had diagnosis which included Multiple Sclerosis, Spastic Hemiplegia, Chronic Respiratory Failure with Hypoxia and Sleep Apnea. R26's Care Plan directed staff to administer oxygen per MD orders, titrate for comfort, 1-4 liters (L). The care plan did not address oxygen tubing changes. R26's medical record lacked direction for oxygen tubing changes. On 10/30/23 at 7:26 p.m., R26 was observed in room, wearing oxygen via nasal cannula, the tubing was either dated for 10/8 or 10/18, the writing made it hard to distinguish if it was a slash between the 0 and 8 or a 1. On 10/31/23 at 10:00 a.m., R26 was observed in room, wearing oxygen via nasal cannula, that appeared to be the same the tubing that was either dated for 10/8 or 10/18, the writing made it hard to distinguish if it was a slash between the 0 and 8 or a 1. On 10/31/23 at 04:17 p.m.,…

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

Based on interview and document review, the facility failed to individualize the care plan to include target behaviors for psychotropic medication use for 1 of 1 (R12) resident. Additionally, the facility failed to have appropriate diagnoses for antipsychotic medication for 2 of 2 (R23 and R185) residents. Findings include: R12's 9/27/23, quarterly Minimum Data Set (MDS) assessment identified R12's cognition was impaired, R12 required staff assistance for cares, had one fall with minor injury since last assessment, took an antipsychotic medication on a routine basis, and had diagnoses of heart failure, hypertension, renal insufficiency, dementia, and schizoaffective disorder. R12's October 2023, Medication Administration Record (MAR) identified R12 had an order for Olanzapine 20 milligram (mg) by mouth at bedtime for schizoaffective disorder bipolar type and Sertraline HCL 150 mg by mouth every morning for schizoaffective disorder bipolar type and somatoform disorder. The MAR further identified an order for Olanzapine/Zyprexa side effect monitoring: observe for signs/symptoms these…

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 an ordered therapeutic diet for 1 of 1 resident (R138) reviewed for provision of therapeutic diets. Findings include: R138's admission Record identified the following diagnoses history of stroke, dysphagia, type 2 diabetes mellitus, cirrhosis of the liver, fracture of left femur, muscle weakness, pulmonary fibrosis, chronic right heart failure, and anemia. R138's 8/29/23, admission Minimum Data Set (MDS) assessment identified R138's cognition was intact, he had no behaviors, required assistance with cares, took scheduled pain medication and rate pain a 5 on scale of 1 -10. R138 received daily insulin injections and was working with speech therapy, physical therapy, and occupational therapy. R138 had plans to return to the community. Review of 8/29/23, Nutritional Care Area Assessment identified R138's diet order as cardiac L2 mechanical textures (moist and soft-textured foods that are easy to chew), thin liquids. R138 had difficulty with chewing present related to edentulism (whole or partially…

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 (R8, R12) resident were appropriately vaccinated against pneumococcal disease upon admission and/or offered updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal guidelines located at https://www.cdc .gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE 65…

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 proper hand hygiene was performed during a medication pass between 2 of 6 residents (R3 and R4) reviewed for medication administration. Findings include R3's admission Minimum Data Set (MDS) 8/23/23, indicated R3 had severe cognitive impairment with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia (lack of oxygen), Alzheimer's disease with late onset, and dementia. During an observation and interview on 10/24/23 at 8:39 a.m., licensed practical nurse (LPN)-A prepared R3's -Duo neb inhalation (breathing medication). At 8:45 a.m. LPN-A entered R3's room as he was seated in a wheelchair. LPN-A administered R3's medications. LPN-A put the Duo neb fluid into the nebulizer reservoir and started the nebulizer machine and placed the mask on R3, stated she set a timer (did not report how long), and left R3 unattended in his room. At 9:07 a.m. R3 remained seated in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to assess and determine safety for self-administration of medications (SAM) for 2 of 6 residents (R3 and R4) reviewed for medication administration. Findings include: R3's admission Minimum Data Set (MDS) 8/23/23, indicated R3 had severely impaired cognition, and diagnoses of chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia (lack of oxygen), Alzheimer's disease with late onset, and dementia. During an observation on 10/24/23, at 8:39 a.m., licensed practical nurse (LPN)-A prepared R3's -Duo neb inhalation (breathing medication). At 8:45 a.m. LPN-A entered R3's room as he was seated in a wheelchair. LPN-A put the Duo neb fluid into the nebulizer reservoir and started the nebulizer machine and placed the mask on R3, stated she set a timer (did not report how long), and left R3 unattended in his room. At 9:07 a.m. R3 remained seated in his wheelchair with the nebulizer mask on his face…

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 insulin was administered in accordance with manufacturer recommendations for 1 of 1 resident (R4) reviewed for insulin administration. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4's did not have cognitive impairment and had diagnoses of diabetes and lack of coordination. MDS further identified R4 received daily insulin injections. R4's medication administration record (MAR) dated 10/9/223, included the physicians order to inject NPH (Human) (Isophane) insulin 10 units subcutaneously at 8:00 a.m. During an observation on 10/24/23 at 9:08 a.m., licensed practical nurse (LPN)-A prepared R4's insulin. During preparation LPN-A did not clean the rubber seal of the insulin flex pen with an alcohol wipe, put the disposable needle on, pulled off the inner needle cap and dialed up 8 units of insulin without priming the needle. At 9:14 a.m. LPN-A administered the insulin to R4 in the abdomen. LPN-A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's environment remained free from accidents as possible to prevent falls for 2 of 3 residents (R2 and R3) reviewed for falls when there was a lack of evaluation of factors to prevent future falls. Findings include: R2's face sheet printed 8/22/23 indicated R2's original admission date was 7/25/19, R2 readmitted to the facility on [DATE], discharged and was readmitted again on 12/26/22. R2's diagnosis included but not limited to chronic obstructive pulmonary disease, abnormalities of gait and mobility, dementia, blindness of right eye, and low vision in left eye. R2's care plan admission date 12/26/22 initiated, revised on: -Revised on 6/15/23, initiated on 7/25/19, R2 was at risk for falls due to deconditioning, weakness, and had a history of falls. Interventions included to anticipate and meet resident needs, to use call light, provide education on fall prevention measures, assure resident that using the call light is not a bother,…

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.