Edenbrook Of St Cloud

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to change soiled clothing for 1 of 3 residents (R54) reviewed for activities of daily living (ADL's). In addition, the facility failed to remove facial hair for 1 of 3 residents (R36) who was dependent on staff for assistance with grooming and personal hygiene. Findings include: R54's quarterly Minimum Data Set (MDS) dated [DATE], identified R54 was cognitively intact and had diagnoses which included: quadriplegia (paralysis that affects both arms and legs) and traumatic brain injury. Indicated R54 was dependent on staff for dressing, bathing and personal hygiene. R54's care plan revised 1/8/24, identified R54 had an ADL self-care performance deficit related to quadriplegia, morbid obesity, weakness and dependency on staff. Interventions included assist of one for dressing and dependent for personal hygiene. During an observation and interview on 5/14/24 at 9:17 a.m., R54 was seated in his electric wheelchair in the therapy room. R54 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure timely assistance with repositioning and failed to implement care planned interventions for 1 of 4 resident (R26) with current pressure ulcers and at risk for further development of pressure ulcers. Findings include: R26's quarterly Minimum Data Set (MDS), dated [DATE], identified R26 had diagnoses which included cognitive impairment, hypertension,dementia and anxiety. R26 required total assistance of two staff for bed mobility and transfers. Indicated R26 was a risk for pressure ulcers, currently had an unhealed pressure ulcer in foot. R26's comprehensive Care Area Assessment (CAA), dated 2/14/24, identified R26 was at risk for skin breakdown and potential pressure ulcers due to requiring total assistance with bed mobility. R26's care plan revised on 5/15/24, identified R26 had actual complications with impaired skin integrity related to a pressure ulcer on the right heel. Indicated R26 was to have heel protectors on while 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 provide hand splinting and range of motion (ROM) services to prevent a potential decrease in ROM for 1 of 2 residents (R11) reviewed who required hand splinting and range of motion for restorative nursing exercises. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 had moderate cognitive impairment and had diagnoses which included stroke, hemiplegia (paralysis on one side of body) and hemiparesis (weakness on one side of body) and aphasia (loss of ability to understand or express speech). Indicated R11 had no behaviors, no rejection of cares, and was dependent on staff for dressing, hygiene and transfers. The MDS lacked identification of R11 being on a restorative nursing program. R11's care plan revised 4/5/24, identified R11 had a self care performance deficit related to hemiplegia, impaired balance, limited mobility and contractures. R11's interventions included resting hand splint on 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 interview and document review, the facility failed to ensure 2 of 5 residents (R2, R44) were offered or received pneumococcal and/or influenza vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC recommendations 3/15/2023, revealed The Center for Disease Control and Prevention (CDC) identified adults age [AGE] of age or older should receive the influenza vaccination annually and adults [AGE] years of age or older who had not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who had previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Pneumococcal 20-valent Conjugate Vaccine (PVC20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. In addition, the CDC identified adults 65 and older who had previously received both PCV13 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.

Based on observation, interview, and document review, the facility failed to maintain safe storage of medications when the nurses left medication carts unlocked and unattended in 2 of 3 medication carts. Findings: On 4/23/24 at 11:48 a.m., licensed practical nurse (LPN)-A gathered supplies to check R2's blood glucose. LPN-A pressed the north medication cart lock partially into the cart. LPN-A walked away from the medication cart in the hall and into R2's room. LPN-A closed the door for privacy. Following the procedure, LPN-A returned to the cart and pulled the medication cart lock out with his fingers, and accessed the contents of the medication cart. LPN-A did not use a key to access the medication cart. LPN-A stated the importance of locking the medication cart when not in attendance was to make sure no medications were stolen. LPN-A stated he trusted the people and the residents at the facility. LPN-A stated the lock on the medication was in working order. LPN-A stated leaving the medication cart unlocked and unattended was not a safe idea. On 4/23/24 at 12:01 p.m., LPN-B 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 maintain infection control practices while conducting blood glucose checks for 2 of 3 residents (R2, R3) reviewed for medication administration. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had a diagnosis of diabetes mellitus type 2. R2's Physician's Order dated 4/15/24, directed to check blood glucose three times daily. On 4/23/24 at 11:51 a.m., after checking R2's blood glucose, licensed practical nurse (LPN)-A was observed to place a contaminated lancet and cotton ball in the cover of the plastic container used to hold R2's glucometer, insulin pens, and blood glucose testing supplies. LPN-A carried the container to the medication cart, and placed the contaminated lancet (a pricking needle, used to obtain drops of blood for testing) in a plastic cup sitting on the top of the medication cart. There were a total of five used lancets in the cup. LPN-A closed the plastic container in the medication…

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 proper glove use and hand hygiene was performed during incontinence care and wound care for 3 of 6 residents (R3, R4, R6) reviewed for infection control. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 needed extensive assistance with toilet use. R4's quarterly MDS dated [DATE], indicated R4 needed extensive assistance with toilet use. R6's Order Summary dated 3/12/24, indicated R6 had orders for wound care to his right heel daily. On 3/7/24 at 4:02 p.m., nursing assistant (NA)-A and NA-B were observed in R4's room assisting with toileting needs. NA-A had 2 pairs of gloves on, NA-B placed a second glove on her right hand. NA-B removed the bed pan from under R4 which contained urine and stool. NA-B cleansed R4's buttocks with wipes that had stool on them. NA-B's right glove had stool on it. NA-B wiped the stool off of her glove with the wipe used to cleanse R4's bottom. Without changing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify resident representative and physician timely following resident change of condition for 1 of 1 residents (R1) who had dehydration and was eventually was hospitalized . Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and had hip fracture, diabetes mellitus and Alzheimer's disease. MDS also identified R1 required assist of two with activities of daily living (ADL)'s and had no swallowing disorder and no weight loss or gain. The MDS indicated R1 weighed 171 pounds. R1's Care Plan dated 10/09/23, indicated to provide set up with eating, encourage resident to follow diet order, and notify MD/NP per order with significant changes. R1's Registered Dietitian-Nutrition assessment dated [DATE], indicated R1 was on a heart healthy regular cardiac diet. The assessment indicated estimated fluid requirements at 1800 milliliters (ml) and her intake was less than 1200 ml. The assessment…

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 timely identification, evaluation and treatment for R1 who was assessed to be at risk for dehydration and had a change in condition affecting her fluid and nutritional intake and medication administration. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and had hip fracture, diabetes mellitus and Alzheimer's disease. MDS also identified R1 required assist of two with activities of daily living (ADL)'s and had no swallowing disorder and no weight loss or gain. The MDS indicated R1 weighed 171 pounds. R1's Registered Dietitian-Nutrition assessment dated [DATE], indicated she was on a heart healthy regular cardiac diet. The assessment indicated estimated fluid requirements at 1800 milliliters (ml) and her intake was less than 1200 ml. The assessment indicated she had no symptoms of dehydration, although was at risk for dehydration. R1's malnutrition risk assessment dated [DATE],…

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

Based on interview and document review, the facility failed to provide all staff education on cultural competence. Findings include: On 9/19/23 at 9:52 a.m., nursing assistant (NA)-A stated she had not received training in cultural competence. On 9/19/23 at 12:07 p.m., licensed practical nurse (LPN)-A stated he had not received cultural competence training. On 9/19/23 at 1:27 p.m., family member (FM)-A stated nobody had inquired about her R1's cultural preferences or practices since he had been at the facility. R1 moved into the facility on 6/29/23. On 9/19/23 at 4:02 p.m., FM-B stated R3 was served pork on several occasions. R3's culture directed R3 not to have any pork. On 9/19/23 at 4:38 p.m., registered nurse (RN)-B stated she had not received cultural competence training from the facility. On 9/20/23 at 11:00 a.m., R3 stated she was never asked about her cultural preferences. R3 stated that her culture prohibits pork, and she had been served pork on several occasions. On 9/20/23 at 1:35 p.m., the director of dining (DOD) stated he had not received training in cultural…

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 dignity was maintained by answering call lights in a timely manner. Findings include: On 9/20/23, at 11:40 a.m., RN-C stated, Call light times are ridiculous. On 9/20/23, at 12:18 p.m., R2 stated she had her call light on and waited over four and a half hours for her wet brief to be changed on 9/17/23. On 9/21/23, at 1:28 p.m., R7 stated, Sometimes I wait for hours. Sometimes they don't come at all, especially on the weekends. R7 stated, I'm suffering. I just cry and cry. R7 stated she continued to be frustrated. On 9/21/23, at 2:06 p.m., the director of maintenance (DOM) stated extended call wait times were not due to mechanical issues. On 9/21/23, at 3:27 p.m., nursing assistant (NA)-E stated call light wait times were extended 9/17/23 evening shift due to short-staffing and two resident falls. On 9/22/23, at 9:37 a.m., the administrator stated there was not a system in place to routinely monitor call light response times. On 9/22/23, at 11:09 a.m., R8 stated, the weekends were the worst waiting for help to go…

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 non-English speaking residents (R1, R3, R6) and/or their families were provided an interpreter, allowing them to be fully informed about their health status in a language they understood. Findings include: R1's care plan indicated he had a communication deficit due to a language barrier. The care plan directed R1 preferred to communicate in Spanish. R3's care plan indicated R3 had a communication deficit related to language barrier. The care plan directed to provide translator as necessary to communicate with the resident. Translator: Somali. R6's care plan indicated R6 had a cognitive/communication deficit due to stroke and language barrier, no longer able to speak English, speaks Somali and Arabic. The care plan directed R6 was able to communicate by: calling translator line, translating with wife or Somali speaking staff member, or communication board. On 9/19/23 at 9:03 a.m., registered nurse (RN)-F stated they have some Spanish-speaking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify a family member of a fall which occurred for 1 of 2 residents (R1) reviewed. Findings include: R1's Medical Diagnoses List indicated R1's diagnoses included cerebral infarction (stroke), heart failure, and chronic pain. R1's Face Sheet indicated his emergency contact was his family member (FM)-A. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had severely impaired cognition, memory problems, and disorganized thinking. The MDS indicated R1 was unsteady on his feet. R1's care plan indicated he was at high risk for falls related to hemiparesis (partial paralysis on one side of the body), impaired cognition, and communication. R1's progress notes lacked an entry, at the time of the incident, for a fall which occurred on 9/13/23. On 9/14/23 a facility document Risk Management (incident report) indicated on 9/14/23 FM-A reported to a floor nurse R1 fell on 9/13/23 at 10:56 p.m. FM-A reported she had a video of the fall, and a lift…

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 develop a care plan which included cultural plans/interventions for 2 of 3 residents reviewed (R1, R3). Findings include: R1's Medical Diagnoses List indicated R1 had diagnoses of cerebral infarction (stroke), neoplasm of prostate (prostate cancer), secondary malignant neoplasm of bone (bone cancer), heart failure, and chronic pain. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1's preferences were not assessed. R1's care plan dated 7/5/23, indicated he had a communication deficit related to language barrier and stroke. The care plan indicated R1's primary language was Spanish. R1's care plan indicated he had impaired cognitive function/dementia or impaired thought process related to stroke. R1's care plan lacked the development or implementation of culturally competent care plan interventions, including food and meals, activities, and interests. R1's nutrition assessment dated [DATE], failed to address dietary cultural…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure 12 of 17 residents Resident (R) R6, R9, R16, R24, R26, R29, R40, R47, R49, R54, R57 and R215, eating in the memory care dining room, were severed at the same time. In addition, the facility failed to ensure that R16 received her medication administered in a private setting. The sample size was 24 residents. Findings include: Review of the facility's policy titled, Privacy and Dignity, revised 01/10/22, revealed, It is the policy of [NAME] Senior Care to provide dignity and privacy for our residents at all times. Privacy is provided during cares. Resident is appropriately covered. 1. During dining observation in the memory care unit on 01/30/23 between 12:45 PM-1:17 PM revealed the following dignity concerns: At table two, at 12:45 PM, R26 already had her tray delivered, and was eating, but R16 did not receive their tray until 12:52 PM. At table five, R24's family member was assisting R24 with her lunch tray at 12:45 PM; however,…

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 observations, policy review, and interviews, the facility failed to ensure that staff washed their hands between assisting residents in the dining room which affected six of 17 residents (Resident (R) R6, R18, R29, R38, R40 and R47), to prevent possible cross contamination. In addition, the facility failed to ensure that staff washed their hands prior to administering medication and did not pour medication into bare hands during medication pass for R16. The sample size was 24 residents. Findings include: 1. Lunch observation in the memory care unit on 01/30/23 between 12:45 PM-1:17 PM revealed the following: At 12:50 PM, Licensed Practical Nurse (LPN) A went between R6 and R18 assisting these residents with cutting up their food using the same utensils that the residents used, all without washing her hands between residents. At 12:58 PM, LPNA was observed going to the medication cart, which was in the hallway on the unit, obtained two cups of med pass for R38 and R40. Upon return to the dining room, she handed R40 the cup of med pass, touching R40's hand, and then 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews the facility failed to notify the responsible party (RP) for 1 of 2 residents (R)18 reviewed for change in condition related to missing anti-seizure medication in December 2022 out of a total sample size of 24 residents. Findings include: Review of the facility provided Face Sheet revealed R18 was admitted to the facility on [DATE] with a diagnosis of epilepsy. Further review revealed that R18 was not his own responsible party but a family member was his RP. Review of the December 2022 Medication Administration Record (MAR), provided by the facility, revealed, Vimpat [antiseizure medication]100 mg BID was not available from the pharmacy on the following dates for the morning shift: 12/18/22, 12/27/22, and/or 12/28/22. Further review revealed that the evening dose was not available on 12/10/22, and 12/27/22. However, on 12/11/22 for the evening shift revealed that the MAR was left blank. Cross Reference: F:755 -D. Interview with R18's family member on 02/01/23 at 12:43 PM,…

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 record review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code the Minimum Data Set (MDS) for hospice services for 1 of 3 residents (R) 22 receiving hospice services out of a total sample of 24 residents. By not ensuring the accuracy of the MDS, these failures placed the resident at risk for unmet care needs of residents. Findings include: During an observation 01/30/23 at 1:34 PM, R22 was observed lying in bed. At this time when attempting to communicate, R22 was using word salad (confused random words) and would only mumble vague words and was not able to make her needs known. Review of R22's undated Face Sheet, found in R22's electronic medical record (EMR) under the Face Sheet tab, revealed R22 was admitted to the facility on [DATE]. Diagnosis included Multiple Sclerosis (progressive damage to brain and spinal cord), Malignant Neoplasm of Bladder, and Malaise. The face sheet indicated R22 was also receiving Hospice services.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure tube feeding equipment was maintained and stored appropriately for 1 of 1 resident (R)12 reviewed for tube feeding out of a total sample of 24 residents. The facility's deficient practice increased the resident's risk of infectious complications. Findings include: Review of R12's undated admission Record, revealed he was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and dementia. Review of R12's admission Minimum Data Set (MDS) dated 01/19/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R12 was cognitively intact. Continued review of the MDS revealed R12 received food via an abdominal feeding tube. Review of R12's Physician's Orders, revealed OK to slurry meds and give per J-tube [jejunostomy tube-feeding tube] .Enteral feed every night shift. Change syringe daily. Review of R12's comprehensive Care Plan revealed no intervention 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 observations, interviews, and record review, the facility failed to ensure respiratory equipment was maintained and stored appropriately for 1 of 1 residents (R) 19 reviewed for respiratory care out of a total sample of 24 residents. The facility's deficient practice increased the resident's risk of respiratory complications. Findings include: Review of R19's undated admission Record, revealed she was admitted to the facility on [DATE] with diagnoses which included respiratory failure with hypoxia (low oxygen levels). Review of R19's admission Minimum Data Set (MDS) assessment 1/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R19 was cognitively intact. Continued review of the MDS revealed R19 was provided oxygen therapy. Review of R19's Physician's Orders, revealed O2 [oxygen] tubing - change weekly date and initial on change, wash filter. Review of R 19's comprehensive Care Plan, revealed no intervention to maintain R19's oxygen filters or external cleaning.…

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, record review,and interviews, the facility failed to obtain medication for 1 of 1 residents (R) 18 related to the administration of a twice a day (BID) anti-seizure medication out of a total sample of 24 residents. This failure increased the risk that R18 would have seizure activity. Findings included: Review of the facility provided Face Sheet R18 was admitted to the facility on [DATE] with a diagnosis of epilepsy. Review of the Order Summary Report (facility provided), dated 01/30/23, revealed Vimpat (anti-seizure medication) 100 milligrams (mg) BID, start date 03/24/20. Review of the December 2022 Medication Administration Record (MAR), provided by the facility, revealed, Vimpat 100 mg BID was not available from the pharmacy on the following dates for the morning shift: 12/18/22, 12/27/22, and/or 12/28/22. Further review revealed that the evening dose was not available on 12/10/22, and 12/27/22. Review of the Progress Note, provided by the facility and dated 12/07/22, revealed Request…

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.