The Estates At St Louis Park LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R1) remained nothing per oral (NPO), receiving nutrition via tube feeding per his hospital discharge orders. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had Parkinson's, hemiplegia and was severely cognitively impaired. In addition R1's MDS indicated he had no behaviors, had impairment in upper and lower extremities, no or unknown for weight loss or weight gain and received feeding via tube feeding and also had a mechanically altered diet, and 51% or more alternative route and 501 cubic centimeters (CC) or more per day by IV (intravenous) or tube feeding, which R1 received tube feeding. R1's Care Plan dated 2/04/25, indicated R1 had Parkinson's and was at risk for malnutrition and dehydration due to dysphagia (swallowing disorder), and received tube feedings per physician order, staff to check placement of tube feeding, residents head of bed to be elevated 30-40 degrees…

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 physician ordered weights were implemented as ordered for 2 of 3 residents (R3 and R4), reviewed for nutrition. Findings include: R3's care plan identified a focus dated 5/30/19, of alteration in nutrition .malnutrition related to history of inadequate oral intakes related to variable oral intakes as evidenced by underweight status .intervention dated 5/28/19, directed staff to have dietary consult as needed for weight gain/loss or other problems noted. An additional intervention dated 6/15/22, directed staff to obtain and record weights at least monthly, and more often as indicated by physician orders. R3's Care Area Assessment (CAA) dated 11/16/23, identified R3 had a potential for nutritional risk due to reduced micronutrient needs as evidenced by hemodialysis .therapeutic diet related to diabetes and End Stage Renal Disease (ESRD), with hemodialysis. R4 had a history of inadequate oral intakes related to variable oral intake,…

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 promote a dignified environment for 3 or 4 residents (108, R2, R49) reviewed for resident rights. Findings include: R108's quarterly Minimum Data Set (MDS) assessment, dated 5/14/24, indicated R108 had severe cognitive impairment and required partial to moderate assistance with activities of daily living (except eating) and ambulation in the unit hallways. During observation on 6/12/24 at 7:00 a.m., R108 and seven other residents were seated out in the dining room. Four of the residents had coffee in front of them and four had empty juice and coffee cups sitting in front of them. No interaction was observed between staff and residents as staff was still getting residents up for the day. During an interview and observation on 6/12/24 at 7:31 a.m., clinical coordinator and licensed practical nurse (LPN)-D stated breakfast was not served until around 8:30 most days, which was a long time for these residents to wait. During observation on…

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 promote a dignified home like environment for 6 or 6 residents (R61, R13, R126, R22, R63, R68). Findings include: R61's Annual Minimum Data Set (MDS) assessment, dated 5/7/24, indicate admission to facility on 11/9/23 and had severe cognitive impairment. In addition, R61 with no impairment of upper and lower extremities, utilized a walker and wheelchair for mobility, and required substantial assistance with toileting and personal hygiene, and dressing. Also, R61 with diagnoses of benign prostatic hyperplasia (enlarge prostate gland making it difficult to empty bladder), polyneuropathy (numbness in extremities), urinary retention, transient ischemic attacks (cerebral stroke affecting brain function), adjustment disorder, and had an indwelling catheter (to drain urine from bladder into a bag). R61's physician orders (PO) dated 11/3/23 included, Foley Catheter: Please apply leg bag during the day & overnight bag during the evening/night. R61's care plan (CP) dated 6/7/23 indicate, Resident has history of…

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, facility failed to ensure mediations were kept locked or under direct observation of authorized staff in areas where residents, staff and visitors could access medications. The deficient practice had the potential to affect 32 current residents on the unit. Findings include: During observation on 6/10/24 at 5:35 p.m., at entrance of the 2S dining room there was an unlocked medication cart. Dining room had 12 residents in the room eating dinner and numerous staff walking past the medication cart transporting residents. During observation and interview with registered nurse (RN)-C on 6/10/24 at 5:36 p.m., RN-C walked up to the unattended medication cart and locked the cart. RN-C stated, nurses should be sure the med carts are locked and laptop should be closed due to privacy. RN-C stated the nurse responsible for the unattended medication cart was not in the area and would try to locate them. During interview with licensed practical nurse (LPN)-B on 6/10/24 at 5:37 p.m., LPN-B stated he was responsible for the unattended medication cart and, it is 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 utilize infection control practices while administering medications through gastrostomy tube for 1 of 1 residents (R93) observed for medication administration, utilize infection control practices while delivering meal trays to resident rooms for 7 of 7 residents (R35, R53, R58, R59, R64, R67, R112) observed for dining, while assisting multiple residents to eat at once for 7 of 33 residents (R2, R3, R14,R23, R33, R55, R80) observed for dining. In addition, the facility failed to implement and maintain enhanced barrier precautions (EBP) for 2 of 2 resident (R16, R93) reviewed for transmission based precautions. Furthermore, the facility failed to mitigate transmission of potential infections in relation to laundering of linens and personal items. Findings include: Med Admin R93 R93's quarterly Minimum Data Set (MDS) dated [DATE] state admission to facility on 4/6/22, was severely cognitively impaired, and diagnoses of hemiplegia…

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

Based on observation and interview, the facility failed to ensure resident records which contained private, medical, and personal information were kept private and not accessible to unauthorized personnel for 1 of 1 residents (R35) reviewed for privacy. Findings include: During observation on 6/10/24 at 5:35 p.m., an unattended medication cart located at entrance of second floor dining room with laptop open to R35 medication list was observed. Dining room had 12 residents in the room eating dinner and numerous staff walking past the medication cart. During observation and interview with registered nurse (RN)-C on 6/10/24 at 5:36 p.m., RN-C walked up to the unattended medication cart and closed the laptop screen. RN-C stated, nurses should be sure the med carts are locked and laptop should be closed due to privacy. RN-C stated the nurse responsible for the unattended medication cart was not in the area and would try to locate them. During interview with licensed practical nurse (LPN)-B on 6/10/24 at 5:37 p.m., LPN-B stated he was responsible for the unattended medication cart and, it…

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 ensure timeliness of person-centered care conferences were conducted to ensure resident goals and preferences were discussed for 1 of 1 residents (R93) reviewed for care conferences. Findings include: R93's quarterly Minimum Data Set (MDS) assessment, dated 3/28/24 identified admission to facility on 4/6/22, was severely cognitively impaired, with diagnoses of hemiplegia (paralysis) affecting right dominant side, stroke, depression, gastrostomy (feeding through a tube into the abdomen), and Parkinson's (progressive brain disorder affecting muscle control, balance and movement). R93's electronic medical record (EMR) indicates MDS assessments were completed on 4/12/22, 7/9/22, 10/5/22, 1/3/23, 3/30/23, 6/9/23, 9/27/23, 12/28/23, and 3/28/24. R93's EMR indicated care conferences were conducted on 1/4/23, 3/29/23, 4/5/23, 10/5/23 and 2/19/24. R93's medical record failed to show care conference were conducted on 4/12/22, 7/22/22, 10/5/22, 6/9/23, 12/28/23. During interview with director of nursing (DON) on 6/13/24 at 8:27 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure routine personal hygiene assistance was provided to 2 of 2 residents (R28 and R56) reviewed for ADLs. In addition, facility failed to implement a communication system to ensure resident needs were met for 1 of 1 resident (R93) whose primary language was not English. Findings include: R28's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified admission to facility on 1/5/12 and intact cognition. During observation on 6/10/24 at 2:13 p.m., R28 laying in bed, dressed and had black matter under her fingernails. During observation and interview with R28 on 6/11/24 at 2:27 p.m., R28 laying in bed, dressed and had black matter under her fingernails. R28 stated, No, no one asks me if they can cleanout my nails. They can be gross if not soaked and taken care of. The aide [nursing assistant] should be asking me at least. During interview with registered nurse (RN)-D on 6/11/24 at 2:27 p.m., RN-D stated she had worked full time…

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 a resident's preferred activities for individual entertainment were available for 1 or 1 residents (R93) reviewed for activities. Additionally, facility failed to comprehensively assess for, and provide, individualized activities for 1 of 1 transitional care unit (TCU) resident (R106). Findings include: R93's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicates admission to facility on 4/6/22, was severely cognitively impaired, and diagnoses of hemiplegia (paralysis) affecting right dominant side, stroke, depression, gastrostomy (feeding through a tube into the abdomen), and Parkinson's (progressive brain disorder affecting muscle control, balance and movement). In addition, R93's preferred language was documented as OTHER. R93's Therapy Recreation Evaluation and Social History evaluation on 4/6/22 state R93 nationality of Vietnamese, and enjoyed fishing, listening to music and watching movies. R93's care plan (CP)…

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 failed to provide services to maintain and/or prevent loss of range of motion and contracture care for 1 of 1 residents (R93 ) reviewed for limited range of motion. Further, the facility failed to maintain a resident's walking program to prevent any loss of independence, strength or range of motion for 1 of 1 resident (R108) reviewed. Findings include: R93's quarterly Minimum Data Set (MDS) assessment dated [DATE] included severely cognitively impaired, and diagnoses of hemiplegia (paralysis) affecting right dominant side, stroke, depression, and Parkinson's (progressive brain disorder affecting muscle control, balance and movement). R93's physician orders (PO) dated 2/1/23 indicates, Tx [treatment] to R[right] hand to protect from skin breakdown: Wash hand with warm soapy water, ensure skin is dried completely, weave gauze between fingers, place ABD (abdominal pads or ABD dressings for large or draining wounds) to palm of hand and wrap with kerlix. Change…

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 pain with mobility (i.e., repositioning) was appropriately monitored and comprehensively re-assessed then, if needed, interventions developed to promote comfort with mobility for 1 of 2 residents (R92) reviewed for pain management. Findings include: R92's Medicare - 5 Day Minimum Data Set (MDS) assessment, dated 5/10/24, identified R92 had intact cognition and demonstrated no delusional thinking. The MDS outlined R92 consumed scheduled and as-needed (i.e., PRN) pain medication, however, did not receive any non-pharmacological interventions during the review period. The MDS recorded R92's pain interview responses (i.e., J0300 to J0600) as, Not assessed. R92's most recent MHM (Monarch Healthcare Management) Pain Evaluation - V3, dated 3/21/24, identified R92 consumed scheduled pain medication; however, did not receive any PRN medication or non-pharmacological interventions for pain. The evaluation outlined a pain interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure post-dialysis access site monitoring was consistently completed and documented to provide continuity of care and reduce the risk of complication (i.e., bleeding, infection) for 1 of 1 resident (R49) reviewed for dialysis care and services. Findings include: R49's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R49 had moderate cognitive impairment and demonstrated no rejection of care behavior. The MDS indicated R49 was diagnosed with kidney disease with dialysis treatment and a stroke with aphasia (a disorder affecting speech). The MDS indicated R49 was able to independently wheel 50 feet, required set-up help for eating, and was dependent on staff for transfers. R49's Order Summary Report dated 6/22/23, indicated an order to monitor for bruit (whooshing sound) and a thrill (a powerful pulse felt at the top of the fistula) every shift. An order dated 6/13/24, indicated nursing staff should monitor and view…

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 comprehensively assess history of past trauma and implement care plan interventions to identify triggers for 1 of 1 residents reviewed (R18) whose diagnoses included post-traumatic stress disorder (PTSD). Findings include: R18's annual Minimum Data Set (MDS) assessment dated [DATE] identified admission to facility on 4/12/23, intact cognition, and diagnoses of seizure disorder, anxiety, depression, schizophrenia, bipolar disorder, and PTSD. R18's care plan (CP) goal dated 4/27/22 indicated, Resident has PTSD, R 18's mother was abusive and she was a victim of sexual assault in 1970, which may have resulted in pregnancy & a coma. R18 interventions included, Staff will utilize trauma informed care when working with resident, Staff will consider past trauma when engaging in work with resident, Consider past trauma when engaging with resident. R18's care plan lacked identified triggers to avoid re-traumatization. R18's nursing assistant 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 interview and document review, the facility failed to address and respond to the consulting pharmacist's (CP) medication regiment review (MRR) for 2 of 5 residents (R75 and R83) receiving psychotropics (a psychoactive medication taken to exert an effect on the chemical makeup of the brain and nervous system) reviewed for unnecessary medications. Findings include: R75's quarterly Minimum Data Set (MDS) assessment, dated 5/9/24, indicated R75 was admitted to the facility on [DATE], had severe cognitive impairment, was independent with ambulation and was receiving the following medications during the look back period; antipsychotics, antianxiety, antidepressants, and opioids. R75's MRR, dated 4/26/24, indicated it was unclear if R75's falls were related to medication and recommended considering reducing R75's Hydroxyzine order to 25 mg at 2:00 p.m. The report included: R75 had multiple falls within the past month and was receiving the following medications that may increase fall risk; Citalopram 20…

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 resident taking an antipsychotic medication had an appropriate diagnosis for use and was monitored for target behaviors for 1 of 5 residents (R83) reviewed for unnecessary medications. Findings include: R83's quarterly Minimum Data Set (MDS), dated [DATE], indicated R83 was admitted to the facility on [DATE], had severe cognitive impairment, was independent with ambulation, and received the following medications during the look back period; antipsychotics and antidepressants. R83's Medical Diagnoses, indicated R83 diagnoses including dementia with behavioral disturbances, major depressive disorder, generalized anxiety. R83's electronic medical record (EMR) lacked evidence of resident specific target behaviors or monitoring for behaviors, R83's MRR, dated 4/26/24, indicated R83 was receiving the following medications; Seroquel 25 mg three times a day, Mirtazapine 7.5 mg every evening (an antidepressant used to treat depression), and Depakote…

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 implement the current standards of vaccinations regarding pneumonia for 1 of 5 residents (R17) over [AGE] years old whose vaccinations histories were reviewed. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R17's facility Immunization Record, print date 6/13/24, indicated he was [AGE] years old. The record indicated he received PPSV23 on 1/31/2013 followed by the PCV-13 on 10/4/2016. The immunization record lacked evidence of…

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 closet doors in disrepair were reported and acted upon in a timely manner to promote a safe, homelike environment for 1 of 1 resident (R92) reviewed whose closet door was broken with exposed nails present. Findings include: A Vulnerable Adult Maltreatment Report, dated 7/2023, identified a general concern about the care center which included, . [it] needs major repairs and there are multiple things that are broken. R92's quarterly Minimum Data Set (MDS)assessment, dated 3/21/24, identified R92 had intact cognition and demonstrated no delusional thinking. On 6/10/24 at 1:46 p.m., R92 was observed lying in bed while in his room. The room had an off-white colored closet with double doors which opened towards the foot of R92's bed. However, the closet door was in disrepair with the door and attached frame being pulled away from the wall several inches exposing multiple construction nails with the bevel-end open to the outside (i.e., room). The door was loose to touch and the closet' interior was visible…

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 resident call light was within reach for 1 of 3 residents (R3) and failed to ensure call light cords were adequately cleaned for 2 of 3 residents (R1, R3) reviewed for call lights. Findings include: R3's annual Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, dependent on staff for toileting, transfer, and personal hygiene, required maximal assistance with bed mobility., and used a power wheelchair. R5 was super morbidly obese and had visual impairment. R3's care plan dated 3/29/24, indicated R5 was at risk for falls and directed staff to keep the call light within reach. During observation and interview on 4/24/24 at 11:27 a.m., R3 was seated in their wheelchair next to the left side of the bed toward the back of the room. R3's call light cord was draped around the lower right corner of the mattress, then down toward the floor at the end of the bed with the button tucked into the top drawer of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide toileting and repositing assistance for a 1 of 1 residents (R3) dependent on staff and failed to follow a resident's preference for getting out of bed due to a lack of Hoyer (a full body mechanical lift used to lift and transfer residents) and sling availability for 2 of 2 resident (R3, R1) reviewed for activities of daily living for dependent residents. This had the potential to affect 15 bariatric residents in the facility who required a Hoyer lift for transfers. Findings include: R3 R3's annual Minimum Data Set (MDS), dated [DATE], indicated R3 was cognitively intact, and was dependent on staff for turning, positioning and toileting. Diagnoses included morbid obesity, chronic pain, chronic kidney disease, irritable bowel syndrome with diarrhea, urinary incontinence, history of urinary tract infection, gout, and peripheral vascular disease. R3's Care Area Assessment (CAA) dated, 4/25/24, triggered for self-care assistance 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 observation, interview and document review, the facility failed to preserve resident's dignity for 3 of 4 residents (R1, R3, R4) reviewed for toileting assistance. Findings include: R1's Face Sheet printed 3/13/24, indicated diagnoses which included chronic systolic heart failure, atrial fibrillation, and type II diabetes. R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated R1 was cognitively intact. R1's care plan dated 3/6/24, indicated toileting interventions that included assist of one for voiding in the urinal, assist of one with bowel movement in bedpan, and check and change every two to three hours as needed. R3's Face Sheet printed 3/13/24, indicated diagnoses which included chronic systolic heart failure, atherosclerotic heart disease, chronic kidney disease, and type II diabetes. R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact, and required a two person assist with toileting. R3's care plan revised on 1/17/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency (SA) immediately (within 2 hours) for 2 of 5 residents (R1, R2) reviewed for allegations of resident-to-resident abuse. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had severely impaired cognition. R1's diagnoses included dementia, depression, and a history of strokes. R2's annual Minimum Data Set (MDS), dated [DATE], indicated R2 had severely impaired cognition. R2's diagnoses included dementia and encephalopathy. On 1/6/24 at 6:45 p.m. a Facility Reported Incident (FRI) submitted to the SA indicated R2 pushed R1 to the ground after a verbal altercation. R1 fell on the floor and sustained a bruise on her forehead and left arm. On 1/10/24 at 3:34 p.m. registered nurse (RN)-A stated he responded to the altercation a few minutes after it had happened. RN-A stated the incident happened on 1/5/24 sometime between 11:00 p.m. and 11:30 p.m. RN-A stated he did…

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 interviews and record reviews, the facility failed to report a missing vulnerable adult to the State Agency (SA) for 1 of 1 resident (R1) who left the facility without staff awareness and was assaulted while out in the community unsupervised. Findings include R1's admission record included diagnosis of alcoholic cirrhosis of liver with ascites (build up of fluid in the belly), alcohol dependence in remission, anxiety disorder, repeated falls, and altered mental status unspecified. R1's significant change Minimum Data Set (MDS) dated [DATE], noted R1 was cognitively intact. R1 was independent with activities of daily living (ADL)'s. R1 required setup help only with eating, personal hygiene, and bathing. R1 was always steady with walker. R1's Release of Responsibility for Leave of Absence (LOA) form, indicated R1 had signed himself out 8 times between 4/22/23 through 8/23/23. The form included: date out, time out, signature of person accepting responsibility, destination contact person phone number, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 20 residents rooms (room [ROOM NUMBER]) was maintained in a way to prevent mold infestation and failed to maintain the ice machine in a sanitary manner which contained a build up of lime and a brown and black substance where 135 residents were identified as potentially receiving ice out of. Findings include: During observation on 5/1/23, at 2:58 p.m. Rm. 284 was observed. The ceiling had a dark brown stain with water stains running down wall to the top of air conditioner. A line of black furry substance extended approximately two to three feet along the top of air conditioner on the wall. During observation on 5/2/23, at 3:14 p.m. Dark brown stain on ceiling, water stains running down wall and black furry substance on the wall along top of air conditioner remain unchanged. On 5/3/23, at 8:21 a.m. housekeeper (HSK)-A was cleaning area and was interviewed and observed Rm. 284 with surveyor. Housekeeper looked at area above air…

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 a dignified toileting routine for 1 of 1 resident (R19) who expressed feelings of degradation over the facility toileting process. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 was cognitively intact and received assistance with all activities of daily living (ADL's). R19's care plan revised on 12/13/22, indicated R19 required assistance with toileting, and directed staff to provide staff assistance with peri-care every 3 hours and as needed (PRN) and to provide incontinent products and assist to change as needed. When interviewed on 5/1/23, at 3:07 p.m. R19 stated that he had previously (at previous facility) used a bedpan for toileting. R19 stated when he was first admitted to this facility, he had asked for a bed pan and was told they do not use bed pans here and was instructed to have a bowel movement in his incontinent brief. Staff would help him clean up. When interviewed on 5/3/23, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure resident was comprehensively assessed for self-administration of medications for 1 of 1 resident (R9), who were observed self-administering medications. R9's quarterly MDS dated [DATE], identified R9 was cognitively intact, and required supervision with ADL's. Findings included: R77's quarterly Minimum Data Set (MDS) dated [DATE], identified cognitively intact. R9's quarterly MDS dated [DATE], identified cognitively intact with diagnosis including lung disorders. During observation and interview on 5/2/23, at 1:30 p.m. R9 was in R77's room and stated a nebulizer machine and multiple vials of medication (budesonide-a steroid inhalation medication) that was on R77's nightstand was his and that he keeps them in R77's room for convenience as he spends time in R77's room frequently. R9 stated he uses the nebulizer machine and medication at least daily. R9 stated, The nurse knows it's in here, how else do you think I got the stuff…

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 R68's face sheet dated 5/4/23, indicated R68's diagnoses included hemiplegia (paralysis of one side of the body), major depressive disorder and type II diabetes mellitus. R68's quarterly MDS dated [DATE], indicated R68 required extensive to full physical assistance from another person for activities of daily living (ADL) including bathing, grooming and personal hygiene. R68 was independent with eating after set up by another person. R68's cognition was intact; her speech was unclear but was usually able to make herself understood. R68's care plan with a print date 5/4/23, indicated R68 was cooperative with cares and required assistance with nail care. R68 sometimes scratched herself and would break her skin. Weekly skin inspected dated 5/1/23, indicated R68's nails were trimmed during her bath on 5/1/23. The note failed to indicate if attempts were made to clean under her nails. On 5/1/23, at 2:33 p.m. R68 was observed with 1/2 inch to ¾ inch long fingernails on both of her hands with an unknown thick, dark…

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 record review the facility failed to ensure treatment for edema was completed as ordered by the physician for 1 of 1 residents (R59) reviewed for edema. Findings include: R59's significant change minimum data set (MDS) dated [DATE], stated R59 required extensive assistance with two persons for dressing. Dressing included donning/removing compression stockings. R59's activities of daily living (ADLs) care area assessment (CAA) dated 3/30/2023, showed R59 needed extensive assistance for most ADLs, which included dressing. R59's cognitive loss CAA dated 4/5/2023, suggested presence of inattention, disorganized thinking, and altered level of consciousness. R59's active orders listed, compression stockings when up two times a day for edema which initiated 3/31/23. The medical record for April and May 2023 showed nursing marked the order as, administered except for two entries in April which had no response listed (4/17/23 and 4/28/23). R59's orders listed to monitor for slight…

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 recommendations for cataract evaluation were acted upon for 1 of 1 resident (R19) reviewed for vision. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 was cognitively intact and was able to communicate needs and wishes without difficulty. R19's care plan revised 3/24/23, indicated R19 to have alteration in vision and wears glasses due to visual deficit. The care plan directed staff to provide assistance to set up Ophthalmology appointments as needed or requested by resident or family. On 5/1/23, at 3:03 p.m. R19 was in his room watching television with no eyeglasses in place. R19 stated his eyes are a total mess and has been trying to get something done with his eyes. R19 stated that he can not see anything clearly and could not make out surveyor face as it was all blurry. He had been seen by the eye doctor at the facility and was informed by the eye doctor that he had cataracts. R19 stated that he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement pressure ulcer interventions for 1 of 3 residents (R40) reviewed who were identified as at risk for pressure ulcer development. Finding include: R40's annual Minimum Data Set (MDS) dated [DATE], identified resident as dependent on staff for all activities of daily living (ADL's) and at risk for pressure ulcers. R40's diagnoses included, dementia and had a stroke with left sided weakness. R40's care plan dated 2/21/23, identified a risk for skin breakdown due to a stroke, left sided weakness, a history of wounds to feet and ankles that spontaneously re-open. Staff were directed to use an air mattress on the bed, encourage and assist to turn and reposition every 2-3 hours and as needed. R40 was to have a protective dressing on the heel, a pressure reducing wheelchair cushion and Prevalon boots (a boot with a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) or a pillow for floating…

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, record review and interview the facility failed to ensure safe medication storage for 1 of 1 residents (R77) who was noted to have medications stored in her room without an order for the specific medication. Findings include: On 5/2/23, at 8:32 a.m. a nebulizer machine was noted on R77's nightstand. Next to the nebulizer machine were seven plastic vials of clear liquid labeled, budesonide (medication used to treat asthma). R77 indicated the machine and medication did not belong to her but belonged to her male friend. She did not use the machine or the medication. R77's medical record confirmed R77 did not have an order for budesonide. On 5/3/23, at 3:04 p.m. licensed practical nurse (LPN)-A confirmed R77 did not have an order for budesonide. LPN-A was not aware that R77 had the medication in her room. On 5/4/23, at 1:30 p.m. director of nursing (DON) indicated she was not aware that R77 had medication stored in her room. DON expected all medications were stored in the appropriate area, such as a medication cart or medication room, unless they are ordered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide or obtain routine dental services for 1 of 1 residents (R114) reviewed for oral/dental health. Findings include: R114's quarterly Minimum Data Set (MDS) dated [DATE], identified she was admitted [DATE], had severely impaired cognition and diagnoses of non-traumatic brain dysfunction and dementia. R114's admission paperwork included an undated and unsigned document with resident's name, date of birth , medical record number and primary's name entitled, HealthDrive Attending Physician Request for Services/Consultation, and indicated under the dental section, poor oral hygiene and, unable to properly care for teeth as reasons to have a dental provider examine the resident. R114's nursing oral/dental evaluation dated 10/3/22, indicated several missing teeth and a lack of dentures. R114's nursing oral/dental evaluations dated 11/15/22 and 2/14/23 indicated several missing teeth, a lack of dentures and that she would need 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.