St Anthony Park Home INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively reassess to help determine what, if any, additional interventions were required to promote healing and reduce the risk of complication after an in-house acquired pressure injury developed for 1 of 2 residents (R56) reviewed for pressure ulcer care. Findings include: R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both short-term and long-term memory impairment, demonstrated hallucinations, and had rejection of care behaviors one (1) to three (3) days during the review period. The MDS recorded R56 was enrolled in hospice care and had several medical conditions including high blood pressure, coronary artery disease (CAD), and Alzheimer's Disease. Further, the MDS contained a section labeled, Section M - Skin Conditions, which recorded R56 was at risk of developing pressure ulcers, however, had no current pressure ulcers during the review period. R56's most recent Braden Scale 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 comprehensively assess for, and implement as appropriate, a nursing functional maintenance program to ensure 1 of 3 residents (R15) maintained and/or improved their highest level of range of motion (ROM). Findings include: R15's quarterly MDS dated [DATE], indicated R15 had severely impaired cognition and required staff assistance with all activities of daily living (ADLs). The MDS indicated R15 had a Functional Limitation in Range of Motion on all extremities. The MDS indicated R15 was not on a restorative nursing program during the look-back period (LBP). R15's care plan, dated 3/20/25, indicated R15 had an ADL performance deficit related to Alzheimer ' s disease and inability to perform self-cares. The care plan outlined R15's daily routine as, she prefers to remain in bed as long as possible, getting up as close to breakfast and lunch as possible, laying back down as soon as possible after meals, and remaining in bed for dinner. 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 complete ongoing pain assessments and timely intervention when signs of pain were observed for 1 of 4 residents (R15) reviewed for pain, with severely impaired cognition. Findings include: R15's quarterly MDS dated [DATE], indicated R15 had severely impaired cognition and required staff assistance with all activities of daily living (ADLs). The MDS indicated R15 was on a scheduled pain medication regimen but had not received any PRN pain medications during the look-back period (LBP). The MDS indicated R15 had non-verbal sounds (crying, whining, gasping, moaning, or groaning) of pain during the LBP, and these indicators occurred three to four days out of the last five days of the LBP. R15's Medical Diagnosis list dated 1/5/24, indicated R15 was diagnosed with Alzheimer's disease, pain in her thoracic spine, and other chronic pain. R15's care plan dated 3/20/25, indicated R15 had chronic pain related to a history of fractures and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives for 1 of 1 resident (R46) reviewed who had grab bars affixed to their bed. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had moderately impaired cognition and no hallucinations, delusions, or rejection of cares. R46 required partial and/or moderate assistance to roll left and right, required substantial/maximal assistance with upper body dressing and transfers, and was dependent with lower body dressing and toileting hygiene. R46's diagnoses included peripheral vascular disease, arthritis, hip fracture, dementia, Parkinson's Disease, and depression. R46's Order Summary Report printed 5/28/25, indicated okay for bilateral assist bars to serve as an enable to promote independence with order date of 11/18/24. R46's bedrail care plan revised 4/14/25, indicated R46 used bedrails related to need for assistance with bed mobility. Interventions included 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 document review, the facility failed to ensure resident choice with meal preferences was attempted and/or honored to promote quality of life for 1 of 1 resident (R35) reviewed who wanted to have fried eggs (i.e., runny yolk) and was told they could not have them. Findings include: The Centers for Medicare and Medicaid (CMS) State Operations Manual Appendix PP, dated 4/2025, identified the Federal regulatory requirements long-term care facilities must abide by in accordance with Federal law. These regulations included F812 which outlined, . To accommodate residents choice for items such as 'sunny side up [eggs]' the facility must use pasteurized eggs only. On 5/27/25 at 8:13 a.m., an initial tour of the kitchen was completed. A series of boxes were stacked on the floor next to the [NAME] walk-in cooler which had been delivered by the food service vendor. Amongst these were two boxes labeled, Pasteurized Eggs. R35's quarterly Minimum Data Set (MDS), dated [DATE], identified R35…

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 medications were re-ordered timely to prevent delay in administration and reduce the risk of complication for 1 of 4 residents (R40) observed to receive medication during the survey. Findings include: R40's annual Minimum Data Set (MDS) dated [DATE], indicated R40 had moderately impaired cognition and was diagnosed with kidney disease and diabetes. The MDS indicated R40 received insulin (an injection used to lower blood sugar) during the look-back period (LBP). R40's order summary dated 5/29/25, indicated R40 had orders for: -Insulin Lispro (fast-acting insulin) three times a day per sliding scale based on blood glucose level (70 - 149, zero units; 150 - 199, 2 units; 200 - 249, 4 units; 250 -299, 6 units; 300 - 349, 8 units; 350 - 399, 10 units; 400 or greater, 12 units and notify provider) -Humulin 70/30 insulin, 52 units in the morning and 44 units in the evening. During an interview and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to take appropriate steps to ensure the proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate final rinse temperature (i.e., 180 F). This had potential to affect all 80 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen. Findings include: On 8/5/24 at 7:06 p.m., a kitchen tour was completed with dietary staff (DS)-A and DS-B present. A single [NAME] Tempstar commercial dishwasher was present along the wall with several hard plastic racks placed in front of the machine on the floor. DS-B loaded several metallic cookware pans onto other hard plastic racks and placed them into the dishwasher. A single, white-colored gauge present on top of the machine which did not move for the entirety of the wash or rinse cycle. A silver-colored plate was mounted to the side 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 ensure resident's needs were addressed in a respectful and dignified manner when a resident (R34) used a call light for help. Additionally, the facility failed to ensure all staff knock on individual resident bedroom doors and introduce themselves prior to entry for 3 residents (R68, R76, R74). Furthermore, the facility failed to provide a dignified dining experience for 3 residents (R21, R31, R68). Findings include: Call Lights R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of hemiplegia (one-side paralysis) and hemiparesis (weakness or the inability to move on one side of the body) after a stroke and high blood pressure. R34's care plan dated 8/30/23, indicated he was dependent on staff/volunteers/family for meeting his emotional, intellectual, physical, and social needs related to his tendency to not seek out activities. The care plan also identified R34's activities of daily living (ADL)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) upon the termination of Medicare A coverage for 1 of 3 residents (R74) reviewed who remained in the nursing home after Medicare A coverage ended. Findings include: R74's Prospective Payment System (PPS) Part A Discharge (End of Stay) Minimum Data Set (MDS) dated [DATE], indicated he was discharged from Medicare Part A services on 7/23/24 and had intact cognition with diagnoses of Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and depression. Under Point Click Care's (PCC) census header, Medicare Part A was identified as R74's primary payer on 6/3/24. Private pay was identified as R74's primary payer on 7/24/24. A Notice of Medicare Non-Coverage (NOMNC) form indicated, a final day of skilled nursing services will be provided on 7/23/24 due to decrease of tube feeding. On 7/26/24, this client's family member(FM)/power of attorney…

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 respond to and resolve a report of missing clothing for 1 of 1 residents (R182) reviewed for grievances. Findings include: R182's quarterly minimum assessment data (MDS) indicated, R182 had severe cognitive impairment, no behaviors, hallucinations, or delusions. R182 had limited range of motion in one side of her body, was dependent with grooming, toileting, dressing, and transfers. R182 was unable to ambulate, needed help to set up her meals, and was able to propel her wheelchair. R182's Clinical Diagnosis record printed 8/7/24, indicated diagnosis of hemiplegia and hemiparesis (paralysis and weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side (area of damaged tissue on the brain), lymphedema (swelling due to build-up of lymph fluid in the body), vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), essential hypertension (an abnormally high blood pressure…

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 allegations of potential abuse were reported in a timely manner to the state agency (SA) for 1 of 1 residents (R21) whose allegations were reviewed. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severely impaired cognition with no hallucinations or delusions, and was dependent on staff for all activities of daily living (ADLs) including bed mobility and transfers. R21's care plan, printed 8/7/24, identified R21 transferred with a Hoyer (mechanical lift) and assist of 2 staff. In addition, R21 was unable to adequately verbalize her needs, Speech is nonsensical, disorganized and unintelligible when she speaks. Furthermore, the care plan identified, my safety is at risk and there is potential for abuse due to: Cognitive Impairment, Dementia, or poor decision making. R21's progress note dated 8/1/24, identified the following entry: Residents son flagged writer to come to his mom's room He said there's 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 record review the facility failed to ensure routine personal care (i.e., incontinent cares, nail care) were provided for 2 of 3 residents (R6, R31) reviewed for dependent activities of daily living (ADL's). Findings include: R6 R6's significant change Minimum Data Set (MDS), dated [DATE], identified R6 had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS outlined R6 was dependent on staff for most personal hygiene needs and was not diabetic. On 8/5/24 at 1:47 p.m., R6 was observed seated in a recliner chair while in his room. R6 had long fingernails present on both hands, with the nail edge both having a dark-colored debris present and being several millimeters (mm) long on multiple nails. R6 was questioned on his nail care and who, if anyone, helps him with it. R6 looked at his nails and expressed aloud, My nails need to be clipped. R6 stated he used to clip them himself, however, had lost the clippers awhile back. R6 stated the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure assessed and care-planned interventions for preventative skin care were consistently implemented for 1 of 1 residents (R31) reviewed for pressure ulcers. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 had severely impaired cognition with no hallucinations or delusions. Diagnoses included: dementia (loss of memory, language, problem,-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety, depression, other frontotemporal neurocognitive disorder (progressive disease of the brain involving frontal and temporal lobes of the brain; can also be referred to as frontotemporal dementia), and polyosteoarthritis (type of arthritis that involves five or more joints at the same time). In addition, R31 was dependent on staff for all ADLs including bed mobility and all hygiene needs. In section H: Bladder and Bowel: section H0300 Urinary Continence: R31 was coded…

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 behaviors of potential wandering were comprehensively assessed and, if needed, interventions placed to ensure safety and prevent elopement for 1 of 1 residents (R330); and failed to ensure fall interventions were implemented to prevent fall and injury for 1 of 3 residents (R64) reviewed for falls and accidents. Findings include: R330 R330's Nurse Admission/readmission 05212021 - V15, dated 7/31/24, identified R330 admitted to the care center from the hospital. R330 was recorded as being alert to person and time, however, not to place or aware of her clinical situation with an option being checked, Short term memory loss. The evaluation concluded with a section labeled, admission Summary, which outlined, . alert and oriented X2 with forgetfulness . assist of one with cares . On 8/5/24 at 2:35 p.m., R330 was observed lying on her bed while in her room which was at the end of a hallway next to a stairwell. R330 smiled at the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R76) residents reviewed for trauma-informed care. Findings include: R76's admission Minimum Data Set (MDS), dated [DATE], identified R76 with moderately impaired cognition and diagnoses included: PTSD, bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, and fibromyalgia (medical syndrome which caused chronic widespread pain). R76's Trauma Informed Care History Assessment, dated 6/27/24, identified R76 as alert, orientated and cognitively intact. The document identified through a question with a radio-button answered yes that R76 experienced any life traumatic events. The assessment form disclosed a traumatic event that happened to R76…

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 act upon the consultant pharmacist's recommendation for 1 of 1 resident (R13) reviewed for unnecessary medications. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact, did not experience hallucinations or delusions and did not refuse cares. MDS indicated R13 needed extensive assistance with transfers, hygiene, bathing, and dressing. R13 needed set up with oral hygiene and eating. R13's Clinical Diagnosis report printed 8/7/24, indicated Parkinson's disease with dyskinesia (disorder of the central nervous system that affects movement, often including tremors), dementia with other behavioral disturbances, neurocognitive disorder with Lewy Bodies (type of dementia characterized by build up of protein deposits in regions of the brain memory, thinking and movement) , essential hypertension(abnormally high blood pressure that's not the result of a medical condition) , and vitamin d deficiency. R13's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to administration of as-needed (PRN) narcotic medication to reduce the risk of potential complications for 1 of 5 residents (R4) reviewed for unnecessary medication use. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and consumed opioid (i.e., narcotic) medication during the review period. R4's care plan, dated 8/5/24, identified R4 had potential for pain due to recent hip surgery. A goal was listed which read, . will not have an interruption in normal activities due to pain through the review date, along with several interventions to help R4 meet this goal including, The resident's pain is alleviated/relieved by: Ice, rest, pain medications. The intervention start date was recorded as, 08/05/2024. R4's Order Summary Report, signed 7/29/24, identified R4's physician orders while at the care center. This…

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 appropriate indication was given for continued antipsychotic medication use for 1 of 5 residents (R68) reviewed for unnecessary medications. Findings include: R68's quarterly Minimum Data Set (MDS) dated [DATE], indicated R68 had severely impaired cognition and was diagnosed with dementia, anxiety, depression, and a stroke. The MDS indicated R68 had no signs of psychosis such as hallucinations or delusions and did not have behavioral symptoms during the look-back period (LBP). The MDS indicated R68 was dependent on staff for all activities of daily living and was receiving hospice services. R68's medical diagnoses report dated 1/16/24, indicated R68 had dementia without behavioral disturbance. R68's Order Summary Report dated 1/16/24, included an order dated 1/16/24, for quetiapine (an antipsychotic medication) 12.5 milligrams (mg) every evening for agitation. R68's care plan dated 1/29/24, indicated R68 had a behavioral…

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 the need for routine dental care (i.e., dental appointment) was assessed and, if needed or wanted, offered to promote oral hygiene and reduce the risk of complication for 1 of 1 resident (R4) reviewed who reported losing their dentures just prior to admission. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 admitted to the care center on 7/9/24 from the acute care hospital. The MDS outlined R4 had intact cognition and demonstrated no delusional thinking. Further, The MDS recorded under, Section L - Oral/Dental Status, R4 had no broken or loosely fitting dentures, abnormal mouth tissue, or obvious cavities with a check placed next to the option reading, Z. None of the above were present. R4's Clinical Census listing, printed 8/6/24, identified R4's current payer source was listed as, MSHO Medicaid. On 8/5/24 at 1:15 p.m., R4 was interviewed and stated she admitted to the care center about a month prior. R4…

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 recommended pneumococcal immunizations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R18) reviewed for immunizations. This had the ability to affect all 80 residents residing the in the facility Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults 19-[AGE] years old with chronic health conditions ., identified persons who received only a PPSV23 had an option to either get a PCV15 or PCV20 a year after the last PPSV23 dose. The conditions listed including alcoholism and cigarette smoking. Further, The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal…

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 take appropriate steps to ensure the proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate final rinse temperature (i.e., 180 F). This had potential to affect all 67 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen. Findings include: On 9/25/23 at 11:41 a.m., an initial kitchen tour was completed with cook (CK)-A and CK-B present. A single [NAME] Tempstar commercial dishwasher was present along the wall with several hard plastic racks placed in front of the machine on the floor. CK-A loaded several metallic cookware pans onto other hard plastic racks and placed them into the dishwasher. A series of wash chemicals, including rinse aide, were present on or around the machine with visible tubing connected to the dishwasher; along with a single, white-colored gauge…

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 water management program was developed and maintained to help reduce the risk of Legionnaires' (Legionella) bacterial growth and subsequent contamination in the facility' water supply and/or storage. In addition, the facility failed to ensure potential signs and symptoms of COVID-19 were acted upon and evaluated (i.e., tested, transmission base precautions implemented) in accordance with current Centers for Disease Control (CDC) guidelines for 2 of 2 resident (R8, R66) reviewed who displayed potential symptoms of COVID-19; and failed to ensure transmission-based precautions (TBP) were implemented as posted for 1 of 2 residents (R38) reviewed in such precautions. These findings had potential to affect all 67 residents, staff, and visitors within the nursing home. Findings include: COVID-19 SYMPTOM TESTING: The CMS QSO-20-38-NH, dated 9/23/22, identified the most recent guidance for COVID-19 testing and management in the nursing…

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.

During observation and interview the facility failed to ensure safe and secure storage of medications and to limit access to only authorized personnel for 2 of 3 medication storage rooms reviewed. Findings include: During observation on 9/26/23 at 9:47 a.m., the door to the third floor medication storage room was observed with door wedged open with no staff around the area. Six narrow and one small portable oxygen cylinders, a Pyxis (medication dispensing machine) with one means of securing medications instead of two. Also, a small, unlocked refrigerator containing medication and a locked large tackle box (with one means of securing contents instead of two) were visible from the dining room and nursing station. During observation on 9/26/23 at 12:45 p.m., third floor medication storage room observed with door wedged open. Six narrow and one small portable oxygen cylinders, a Pyxis (with one means of securing medications instead of two). Also, a small, unlocked refrigerator containing medication and a locked large tackle box (with one means of securing contents instead of two) were…

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 provider and resident representative were notified in a timely manner of a change in status for 1 of 1 residents (R66) who had new onset of signs and symptoms of a possible infection and was tested for COVID-19. Findings include: R66's quarterly Minimum Data Set (MDS) dated [DATE], indicated R66 had severe cognitive deficits, required supervision for eating, limited assistance for transfers and was extensive assistance for all other activities of daily living (ADLs). R66's diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies (a brain disorder that can lead to problems with thinking, movement, behavior, and mood.), falls, diabetes, end stage heart failure, liver cancer, and cirrhosis of the liver (impaired liver function caused by the formation of scar tissue). R66's Care Area Assessment (CAA) dated 6/20/23, indicated R66 triggered for delirium, cognitive loss/dementia, communication, ADL function, falls, nutrition,…

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 timeliness of person-centered care conferences for 2 of 2 (R45, R53) and to include review and revision by an interdisciplinary team and the resident in adjusting their care plan and making decisions about his or her care. Findings include: R45's quarterly Minimum Data Set (MDS) dated [DATE], identified R45 with intact cognition, and required extensive assistance with all activities of daily living (ADL's). In addition, R45 had diagnosis of Parkinson's, delusions, spinal cord injury, anxiety, paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and depression. R45's previous MDS assessments were 5/18/23, 2/15/23, and 11/17/22. R45's Care conference notes titled, Social Service Care Conference-IDT were dated 8/31/23, 4/25/23, and 8/25/22. R45's electronic medical record (EMR) failed to indicate a care conference was completed within the time frame for MDS assessments for 5/18/23, 2/15/23 and 11/17/22. R53's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to comprehensively assess significant weight changes for 1 of 1 residents (R51) reviewed for nutritional status. Findings include: R51's quarterly Minimum Data Set (MDS) dated [DATE], indicated R51 had intact cognition, was independent with eating and required extensive assistance for all other activities of daily living (ADLs). R51's diagnoses included atherosclerotic heart disease, depression, diabetes, high cholesterol, osteogenesis imperfecta (genetic disease resulting in brittle bones), and high blood pressure. R51's Care Area Assessment (CAA) dated 4/25/23, indicated R51 triggered for ADL function, psychosocial well-being, mood state, nutrition status, pressure ulcers, and psychotropic drug use. R51's care plan dated 12/10/22, indicated R51 had diabetes. Interventions included monitoring/documenting/reporting signs and/or symptoms of hyperglycemia (high blood sugar) including increased appetite, noncompliance with prescribed diet and malnutrition.…

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 oxygen tubing was changed according to standards of care to prevent possible respiratory infections for 2 of 2 residents (R18, R54) who used oxygen. Findings include: R18 R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 was unable to complete the Brief Interview for Mental Status (BIMS) and had severe cognitive deficits, was totally dependent on staff for eating and required extensive assistance for all other activities of daily living (ADLs). R18's diagnoses included toxic encephalopathy (a brain disorder caused by exposure to a neurotoxic substance), acute respiratory failure with hypoxia (low oxygen), pneumonia due to COVID-19, cardiac arrhythmias, deep vein thrombosis and stroke. R18's orders dated 7/3/23, indicated R18's oxygen tubing was to be changed and dated every Monday, and received 2 liters per minute (lpm) of oxygen by nasal cannula to maintain an oxygen saturation level of greater than 90%. During…

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 psychotropic medications were reviewed for the appropriateness of a gradual dose reduction (GDR) for 1 of 1 residents (R54) reviewed for unnecessary medications. Findings include: R54's quarterly MDS dated [DATE], indicated R54 had severe cognitive deficits, required limited assistance for toileting, dressing and transfers, and supervision for bed mobility and personal hygiene. R54's diagnoses included dementia with behavioral disturbances, anxiety, and visual hallucinations. R54's care plan dated 8/10/22, indicated R54 received psychotropic medications. Interventions included consulting with the provider and pharmacy to consider dose reductions at least quarterly, and discuss the need for R54's ongoing use with the provider and family. R54's orders dated 9/13/23, indicated R54 had not had a GDR completed since his sertraline (an anti-depressant) was increased on 8/16/22, from 25 milligrams (mg) to 50 mg. The orders also indicated R54 had not…

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