Good Samaritan Society - Maplewood

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to weekly skin assessments which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all 61 residents in the facility. The Certification and Survey Provider Enhanved Reports (Casper)-3 assessment (data was converted to quality measures (QM) to evaluate nursing homes performance) dated 8/11/24, identified the following previous deficiency by month and year. -F686 Treatment/services to prevent/heal pressure ulcers at a scope and severity level of a D. See also F686 Based on interview and document review, the facility failed to ensure weekly skin assessments were completed for 2 of 3 (R3, R12) residents reviewed for pressure ulcer risk. Monthly QAPI meeting minutes dated 5/26/23, indicated performance improvment plan (PIP) for high risk…

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 R42 R42's face sheet printed [DATE], indicated diagnoses of pneumonia, heart failure, and diabetes R42's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R42 had moderate cognitive impairment, no upper or lower extremity impairment, uses a wheelchair, dependent on staff for toileting hygiene, bathing, lower body dressing, and substantial assist for personal hygiene and bed mobility. R42 was frequently incontinent of urine and always incontinent of bowel. R42 has moisture associated skin damage (MASD) R42's careplan indicated R42 required enhanced barrier precautions related to open wounds. Interventions included wearing gown and gloves when performing high contact are activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, and/or wound care. R42's Kardex printed [DATE] directed staff to don gown and gloves when performing high contact care activities such as dressing, transferring, bathing, hygiene, changing linens, repositioning, and wound care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure reclining foot rests functioned appropriately for 1 of 1 resident (R212) and failed to ensure a clean communal shower room which had the potential to affect all residents who used the shower room. Findings include, R212's comprehensive Minimum Data Set (MDS) in progress dated 8/15/24, indicated intact cognition, had coronary artery disease and hypertension (high blood pressure), acute myocardial infarction (heart attack), presence of an aortocoronary bypass graft, and had an encounter for surgical after care following surgery on the circulatory system. R212's physician orders form indicated the following order: 8/16/24, bumetanide 1 milligram (MG) by mouth daily for edema (fluid collecting in body tissues) and shortness of breath. R212's care plan dated 8/12/24, identified R212 took a diuretic. During interview on 8/19/24, at 1:13 p.m., R212 stated she mentioned to a few staff that the recliner chair did not work when trying to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 3 of 4 residents (R18, R4, R12) reviewed for skin alterations had weekly skin observations completed. Furthermore, the facility failed to ensure bruising was assessed and monitored for 1 of 3 resident (R12 ) reviewed for bruising and a skin tear was assessed and monitored for 1 of 2 residents (R18) reviewed for pressure injury. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. R18's MDS also indicated R18 was at risk for pressure injury, was always incontinent of bladder and bowel, and was dependent on staff for mobility. R18's care plan revised 4/3/24, indicated R18 had potential for pressure ulcer development related to impaired mobility, weakness, history of falls, and use of a diuretic. R18 further had a known pressure insult of suspected deep tissue injury to both feels. Interventions included…

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 comprehensive care plans were developed for 1 of 1 resident (R50) and failed to ensure non-pharmacological interventions were developed and implemented for 1 of 1 resident (R110) reviewed for psychotropic drug use. Findings include: R50's admission Minimum Data Set, dated [DATE], indicated severe cognitive impairment, did not have little interest or pleasure in doing things, and did not feel down, depressed, or hopeless, did not have physical, verbal, or other behaviors, had diagnoses of dementia and depression and took an antipsychotic and antidepressant medication. R50's care area assessment (CAA) worksheet dated 7/16/24, indicated R50 took duloxetine (an antidepressant) and aripiprazole (an antipsychotic) for depression and psychotropic drug use would be addressed in the care plan in order to minimize risks. R50's physician orders indicated the following orders: 7/4/24, aripiprazole 20 milligrams (MG) by mouth once daily. 7/4/24, duloxetine…

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 incontinent care was provided for 1 of 3 residents (R18) reviewed for dependent activities of daily living (ADL's). Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. R18's MDS also indicated R18 was always incontinent of bladder and bowel and required maximal assistance from staff for incontinent cares. R18's care plan revised 4/3/24, indicated R18 had incontinence related to impaired mobility, weakness, and use of a diuretic. Interventions included to monitor for signs of urinary tract infection, use incontinence products, check for incontinence frequently and provide brief change and incontinence cares as needed. R18's [NAME] printed 8/20/24, indicated R18 required frequent checks for incontinence and assistance with incontinence cares. A continuous observation on 8/20/24 at 10:58 a.m., R18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1 of 2 residents (R18) who were at risk for pressure ulcers were repositioned in a timely manner to prevent pressure injury. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. R18's MDS also indicated R18 was at risk for pressure injury and was dependent on staff for mobility. R18's skin Care Area Assessment (CAA) indicated R18 was at risk for pressure injury due to immobility and weakness. A review of R18's nursing and provider orders showed: -on 3/21/24, R18 required cleansing and barrier cream to be applied to wounds on the right buttock and posterior thigh. -on 7/24/24, R18 required cleaning and skin prep applied to the right heel daily. R18's weekly skin observation dated 7/25/24, indicated R18 had a healing right heel wound and no other skin concerns. R18's medical record lacked evidence weekly…

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 speech therapy recommendations were followed for 1 of 3 residents (R18) reviewed for nutrition. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. R18's MDS also indicated R18 had no signs or symptoms of a swallowing disorder and required set up and clean up for meals. R18's diagnoses list printed on 8/20/24, indicated R18 had a secondary diagnosis of dysphagia (impaired swallowing). R18's hospital Discharge summary dated [DATE], indicated R18 had been hospitalized for an ankle fracture. R18 was assessed by speech therapy for dysphagia and had recently advanced to thin liquids and no straws. R18's hospital discharge orders dated 6/14/21, indicated R18 required a regular diet with thin liquids and no straws. R18's discharge orders also indicated R18 to follow speech therapy. R18's provider order dated…

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 1 of 1 residents (R12) reviewed for bedrails. R4's significant change Minimum Data Set (MDS) dated [DATE], indicated, intact cognition and diagnoses of displaced bicondylar fracture of right tibia, atrial fibrillation, and chronic kidney disease (CKD). It further indicated R4 required assistance from staff with most activities of daily living (ADL) and mobility. R4's physician's order dated 5/7/24, indicated okay to install assist bar. Follow manufacturers recommendations and specifications to promote independence with bed mobility. Risk vs benefit have been reviewed and consent form signed. No directions specified for order. R4's Informed Consent for Bed Rails, was signed by R4 on 5/13/24. During observation and inteview on 8/19/24 7:59 a.m., R4 was sitting in her room, registered nurse (RN)-D verified the bilateral side rails on her bed and stated all the residents have them for positioning. RN-D stated the resident needs to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the consulting pharmacist (CP) failed to address an appropriate indication for an antidepressant for 1 of 1 resident (R212) reviewed for psychotropic medications. Findings include: R212's comprehensive Minimum Data Set (MDS) in progress dated 8/15/24, indicated intact cognition, had coronary artery disease and hypertension (high blood pressure), acute myocardial infarction (heart attack), presence of an aortocoronary bypass graft, and had an encounter for surgical after care following surgery on the circulatory system. Further, R212 did not have little interest or pleasure in doing things, and did not feel down, depressed, or hopeless. R212's physician orders dated 8/9/24, indicated R212 took bupropion (an antidepressant) HCL ER (extended release) 150 mg by mouth two times a day for status post CABG (coronary artery bypass grafting). R212's Medical Diagnosis form dated 8/21/24 at 1:39 p.m., indicated the following diagnoses: encounter for surgical aftercare following…

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 R50's admission Minimum Data Set, dated [DATE], indicated severe cognitive impairment, did not have little interest or pleasure in doing things, and did not feel down, depressed, or hopeless, did not have physical, verbal, or other behaviors, had diagnoses of dementia and depression and took an antipsychotic and antidepressant medication. R50's care area assessment (CAA) worksheet dated 7/16/24, indicated R50 took duloxetine (an antidepressant) and aripiprazole (an antipsychotic) for depression and psychotropic drug use would be addressed in the care plan in order to minimize risks. R50's physician orders indicated the following orders: • 7/4/24, aripiprazole 20 milligrams (MG) by mouth once daily. • 7/4/24, duloxetine 30 mg by mouth every evening, and 60 mg by mouth every morning. R50's orders lacked any monitoring for side effects of duloxetine and aripiprazole. R50's care plan was reviewed and lacked information R50 had depression and further lacked any monitoring for side effects of duloxetine and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmacy services for one of one resident (R1) reviewed for medication administration. R1 did not receive her oxycodone (pain medication) when it was available in the facility's medication dispensing kit. Findings include: R1's admission record printed on 5/14/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnoses of falls, generalized deconditioning, and left gluteal hematoma. R1's additional diagnoses included contusion of lower back and pelvis, repeated falls, dementia, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease stage 3, muscle weakness, and difficulty walking. R1's minimum data set (MDS) dated [DATE] indicated R1 had a brief interview for mental status (BIMS) score was 14, indicating she was cognitively intact. R1's pain documentation on 4/22/24 at 10:23 a.m., indicated R1 had a pain score of eight out of ten. R1's pain documentation on 4/22/24 at 12:06 p.m., indicated R1 had a pain…

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, interviews, and document review the facility failed to follow transmission-based precautions to prevent the spread of SARS-CoV2 (Covid-19), influenza, and clostridium difficile (c. diff) for 4 of 4 residents evaluated for infection control. The facility failed to practice proper hand hygiene, post the proper signage at a doorway, adhere to proper personal protective equipment (PPE), sanitize medical equipment following resident usage, and have proper doffing (taking off PPE) areas. This deficient practice had the potential to infect all 61 residents who resided at the facility. A Minnesota Department of Health resource titled Covid-19 Source Control (Masking), PPE, and Testing grid dated 9/15/23, https://www.health.state.mn.us/diseases/coronavirus/hcp/ppegrid.pdf indicated when a resident has tested positive for COVID-19, staff's PPE should consist of respirator, eye protection, isolation gown, and gloves. A Minnesota Department of Health resource titled Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities dated 1/10/23,…

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 immediate report, but not later than two hours after the allegation is made, to the state agency (SA) allegations of employee to resident physical and verbal abuse for 1 of 1 resident (R1) reviewed for abuse. R1's admission Minimal Data Set (MDS) date 11/5/23 indicated R1 had no cognitive deficits. R1 was dependent with toileting and lower body dressing and transfers. She required maximum assistance with upper body dressing and showering. R1's pertinent diagnoses were metastatic breast cancer, anxiety disorder, morbid obesity, and a pathological fracture of the left tibia (shin bone). A facility incident report dated 11/22/23 indicated R1 reported NA-A had yelled at her, telling her that no one liked her. R1 also stated NA-A ripped her brief off and hurt her hip during cares. NA-A made her feel bad for needing help. NA-A turned off all her lights and left her with no way to turn the lights on or call for help. R1 stated she was being abused by NA-A because of the treatment and the way her brief was taken off by NA-A. R1…

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 allegations of verbal and physical abuse were thoroughly investigated for 1 of 1 resident (R1) reviewed. R1 reported allegations of rough treatment leading to pain when staff would not stop a catheter procedure upon her request. In addition, R1 reported allegations of verbal and physical abuse by a nursing assistant (NA). A thorough investigation was not completed. Neither complaint allegations were reported to the state agency. The findings include: According to a facility incident report dated 11/22/23 R1's husband arrived at 1:30 p.m. to talk to R1 about what she believed happened to her with an encounter with staff member, NA-A that morning. R1 reported NA-A yelled at her, saying no one liked her. R1 stated NA-A ripped her brief off and hurt her hip. NA-A made her feel bad for needing help. NA-A also turned off all her lights and left her with no way to turn the lights on or call for help. R1 stated she had been abused by NA-A because of this treatment and the way her brief was taken off by NA-A. R1 called the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to develop a comprehensive person-centered care plan for mental and psychosocial needs including prevention, interventions, measurable objectives, and goals for 1 of 1 resident (R1) reviewed. Findings include: R1's physician order dated 10/31/23 was for lorazepam (an anti-anxiety agent) oral tablet 0.5 milligrams (mg) three times a day. R1's care plan dated 10/31/23 - 12/5/23 did not indicate any focus, goal, or interventions for R1's anxiety. R1's physician order dated 10/31/23 was for Alprazolam (an anti-anxiety agent) tablet 0.25 mg by mouth every eight hours as needed for anxiety until 11/10/23. Notify provider on 11/10/23 of need to reassess medication. R1's physician order dated 10/31/23 was for hydroxyzine HCL (anti-anxiety agent) tablet 50 mg by mouth every six hours as needed for anxiety for ten days. Notify provider on 11/10/23 of need to reassess medication. R1's trauma assessment dated [DATE] consisted of one question, 1. Have you ever…

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 medical record was complete and accurately documented for nursing and/or other licensed professional notes for 1 of 1 resident (R1) reviewed when R1 had a straight catheterization procedure that was not recorded in the medical record for R1. Findings include: American Nursing Association, Principles for Nursing Documentation 2010, https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf indicated documentation of nurses work is critical for effective communication with others and other disciplines. It provides a basis for demonstrating and understanding nursing contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. It is how nurses create a record of their services for use by communication within the health care team, communication with other professionals, credentialing, legal, regulation 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 ensure water and ice dispensing machines were clean and free of excess mineral build up or cleaned on a regular schedule. This had the potential to affect all 59 residents residing in the facility. Findings include: During observation on 9/27/23 at 2:40 p.m., the ice/water machine on the post acute kitchenette had some unidentified brown substance on the drip tray and a small amount of white scale build up in and around the ice and water dispensing chutes. During observation on 9/27/23 at 2:44 p.m., the ice/water machine on the north unit had an excessive amount of white scale built up on the drip tray as well as in and around the ice and water dispensing chutes. During interview on 9/27/23 at 2:50 p.m., cook (C)-A stated the ice/water machine had a lot of scale build up and that maintenance was responsible to clean that. C-A further stated that the staff used this machine to dispense ice and water for the resident's consumption on the North unit. During interview on 9/28/23 at 8:04 a.m., food service…

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 resident status was accurately reflected in the Minimum Data Set (MDS) for 1 of 1 residents (R46) reviewed for anticoagulants. Finding include: Centers for Medicare/Medicaid Service (CMS) long-term care (LTC) resident facility assessment instrument (RAI) 3.0 users manual version 1.17.1 dated 10/19, identified in section N medications under coding instructions indicated record the number of days an anticoagulant medication was used by the resident at any time during the 7-day look back period. Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. R46's initial assessment dated [DATE], identified R46 received six days of anticoagulant medication during the look-back period. R46's physician order's reviewed on 9/27/23 indicated R46 had an order in place for Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) one tab by mouth daily for lacunar stroke; however, it lacked any 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure weekly skin assessments were completed for 2 of 3 (R3, R12) residents reviewed for pressure ulcer risk. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was moderately cognitively impaired, required extensive assist of two for bed mobility, no behaviors exhibited, no rejection of care, and at risk for pressure ulcers. R3's pressure injury Care Area Assessment (CAA) dated 6/28/23, indicated R3 was provided a pressure redistribution mattress. R3 was assessed routinely for amount of risk for skin breakdown. Staff assist R3 frequently and encourage significant offloading with pillows. R3's medical diagnosis sheet undated, indicated R3's diagnosis was acute on chronic diastolic (congestive) heart failure (CHF - heart failure which is characterized by signs and symptoms of heart failure and a left ventricular ejection fraction [LVEF] greater than 50%), type II diabetes, and chronic kidney disease. R3's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure an ordered range of motion (ROM) program was provided consistently for 1 of 1 resident (R22) reviewed for positioning and mobility. Findings include R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was cognitively intact, required extensive assistance of two staff for bed mobility and transfers. Further, no exhibited behaviors including no rejection of care. R22's MDS revealed no active or passive ROM completed. R22's rehabilitation potential Care Area Assessment (CAA) dated 3/29/23, lacked any direction for ROM program. R22's care plan revised 5/9/23, indicated R22 had a need for restorative intervention due to limited physical mobility with interventions of active ROM exercises program to bilateral upper and lower extremities under the guidance of the restorative nursing assistant 1x/day 2 days/week. R22's ROM administration record dated September 2023, indicated ROM was provided to R22 only one time 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.