The Emeralds At St Paul LLC

Based on interview and record review the facility failed to ensure medical records were accurate and readily accessible for 1 of 1 resident (R1) reviewed for pressure ulcers. Findings include:On 7/14/25 the facility had provided electronic health record (EHR) access to review resident records. The viewable access to R1's record included care plan history dates, however, when printed the dates were inconsistent with what was displayed that was readily accessible. The facility provided R1's care plan on 7/14/25 at 7:51 a.m. This care plan included a communication focus that identified an initiated date of 4/9/25, Resident has Alteration in communication R/T [related to] Placement of Tracheostomy D/T [do to] chronic respiratory failure, HOH [hard of hearing], No speech. and Resident often refuses to remove pocket talker device. The corresponding goals were initiated on 4/9/25 with revision dates of 7/9/25 (did not identify what the revisions were); the goals included resident will have adequate communication as evidenced by: ability to communicate basic needs and Residents needs will…

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 report lack of supervision incident (6/7/25) and elopement (6/13/25) was reported timely to the State Agency (SA) for 1 of 1 resident (R1) reviewed for elopement. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no behaviors, used a walker and wheelchair, was independent with walking and wheeling, had no upper or lower extremity impairments, and used a wander/elopement alarm daily. Diagnoses included diabetes, dementia, malnutrition, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). R1's most recent elopement assessment on 11/13/24, identified R1 had a habit/history of wandering or attempts to leave the unit/building and was able to ambulate or able to self-propel his wheelchair. R1's nurse progress note dated 6/7/25 at 9:34 a.m., identified R1 was found seated at the back of the building near the kitchen door. Reception staff reported R1 left the building around 5:30 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 interview and document review the facility failed to ensure a thorough investigation for an incident that involved the lack of required supervision for 1 of 3 residents (R1) reviewed who required supervision. R1 was found outside the facility on 6/7/25 in an unsafe unauthorized area.Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no behaviors, used a walker and wheelchair, was independent with walking and wheeling, had no upper or lower extremity impairments, and used a wander/elopement alarm daily. Diagnoses included diabetes, dementia, malnutrition, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). R1's nurse progress note dated 6/7/25 at 9:34 a.m., identified R1 was found seated at the back of the building near the kitchen door. Reception staff reported R1 left the building around 5:30 a.m. and had his Wanderguard in his pocket. R1 returned at 7:20 a.m. and appeared to be fine. R1 did not recall how he exited the building.…

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 assessment accurately reflected a resident health status for 1 of 3 residents (R1) reviewed when R1's significant change of status did not reflect R1's pressure ulcers. Findings include: R1's quarterly Minimum Data Set, dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 14 indicting R1 was cognitively intact. R1's hospital Discharge summary dated [DATE], received by the facility 3/19/25 indicated R1 was discharged with hospice services. R1 had the following wounds: -Wound first assessed on 3/17/25 on his coccyx (tailbone) the wound was identified as moist and blanchable (skin discoloration that disappears pressed upon and return when pressure is released indicating the blood vessels in the areas are occluded therefore blood flow is obstructed), the peri wound (area surrounding the wound) was excoriated, red and moist. Mepilex dressing was used to cover the wound following cleansing.…

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 attempt alternative devices before the use of bedrails on residents beds, assess the residents for risk of entrapment, ensure bed dimensions were appropriate for 2 of 2 residents (R1, R2) reviewed for bed rails. In addition, the facility failed to use caution as R1 had bed rails used in conjunction with an air mattress. Findings include: Food and Drug Administration (FDA) guidelines Recommendations for Health Care Providers about Bed Rails 2018 indicated health care providers should base the use of bed rails on individual resident assessments to ensure the individual is an appropriate candidate to reduce the risk of entrapment. Recommendations made for health care providers to evaluate the individual's need, to use the guidance documented Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to have knowledge that not all bedrails, mattresses, and bed frames are interchangeable; check the manufacture instructions,…

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 conduct regular inspections of bed frames, mattress, and bed rails as part of the regular maintenance program to identify areas for entrapment for 2 of 2 residents (R1, R2) reviewed for bed rails. Findings include: Food and Drug Administration (FDA) guidelines Recommendations for Health Care Providers about Bed Rails 2018 indicated health care providers should base the use of bed rails on individual resident assessments to ensure the individual is an appropriate candidate to reduce the risk of entrapment. Recommendations made for health care providers to evaluate the individual's need, to use the guidance documented Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to have knowledge that not all bedrails, mattresses, and bed frames are interchangeable; check the manufacture instructions, health care providers are to avoid the routine use of adult bed rails without first conducting an individual patient or…

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 report an allegation of abuse and chemical ingestion for 1 of 3 residents (R1) reviewed for incidents and abuse allegations. Findings include: Gentell Dermal Wound Cleanser is a skin cleanser for all types of wounds. According to the gentell product information website, the ingredients include purified water, laurel glucoside, cocamidopropyl betaine, sorbitol, sodium laureth sulfate, polysorbate-80 lactic acid, triethanolamine, imidazolindinyl urea, disodium EDTA and methylparaben. The bottle indicates to seek medical attention or contact the poison control center if swallowed. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was severely cognitively impaired and was independent in activities of daily living besides toileting. R1's face sheet dated 4/21/25, indicated R1 had diagnoses of chronic respiratory failure, paranoid schizophrenia, tracheostomy status, and dependence on ventilator status. R1's care plan…

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 investigate an allegation of abuse and chemical ingestion for 1 of 3 residents (R1) reviewed for incidents and abuse allegations. Findings include: Gentell Dermal Wound Cleanser is a skin cleanser for all types of wounds. According to the gentell product information website, the ingredients include purified water, laurel glucoside, cocamidopropyl betaine, sorbitol, sodium laureth sulfate, polysorbate-80 lactic acid, triethanolamine, imidazolindinyl urea, disodium EDTA and methylparaben. The bottle indicates to seek medical attention or contact the poison control center if swallowed. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was severely cognitively impaired and was independent in activities of daily living besides toileting. R1's face sheet dated 4/21/25, indicated R1 had diagnoses of chronic respiratory failure, paranoid schizophrenia, tracheostomy status, and dependence on ventilator status. R1'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 assess and monitor a resident for bruises, pulse oximeter alarms and after ingesting wound spray for 1 of 3 residents (R1) reviewed for assessment and monitoring. Findings include: Gentell Dermal Wound Cleanser is a skin cleanser for all types of wounds. According to the gentell product information website, the ingredients include purified water, laurel glucoside, cocamidopropyl betaine, sorbitol, sodium laureth sulfate, polysorbate-80 lactic acid, triethanolamine, imidazolindinyl urea, disodium EDTA and methylparaben. The bottle indicates to seek medical attention or contact the poison control center if swallowed. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was severely cognitively impaired and was independent in activities of daily living besides toileting. R1's face sheet dated 4/21/25, indicated R1 had diagnoses of chronic respiratory failure, paranoid schizophrenia, tracheostomy (procedure to help…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a sufficient number of licensed nurses had the necessary training on vest therapy treatments and cough assist therapy treatments for 6 of 6 residents (R1, R3, R4, R5, R6, and R7) reviewed who had orders for vest therapy treatments and 8 of 8 residents(R1, R5, R8, R9, R10, R11, R12, and R13) reviewed who had orders for cough assist therapy. Findings include: R1's factsheet printed 1/29/25 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of muscular dystrophy. R1's additional diagnoses included chronic obstructive pulmonary disease and shortness of breath. R1 discharged from the facility on 1/22/25. R1's admission hospital paperwork dated 1/17/25 indicated R1 was to receive vest therapy twice a day and a cough assist therapy as needed. R1's provider order dated 1/17/25 indicated the nurse practitioner (NP) ordered the cough assist treatment and licensed nurses would administer the treatment two times a day and as needed…

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 right to be free from abuse for 2 of 3 residents (R1 and R2) reviewed when the facility did not comprehensively assess R1 and R2 for vulnerabilities for sexual abuse. R1 had an extensive mental health disease leading to impaired judgement, altered decision making, impaired insight, and hypersexual arousal. R2 had history of alcohol abuse and inappropriate and unwanted sexual behaviors with female staff and residents. Findings include: R1's Minimum Data Set (MDS) dated [DATE] indicated she had normal cognition, schizophrenia (affects ability to think, manage emotions, and make appropriate decisions,) bipolar (personality shifts from depression or mania affecting ability to think clearly,) depression, dependent personality disorder (need for others to care for her, trouble making decisions, and feeling helpless without support from others.) In addition, she had diabetes, and heart failure. R1's Associated Clinical Psychology (ACP) note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to follow the care plan interventions for inappropriate sexual behavior, intoxication, and develop a care plan for behavioral health for 2 of 3 residents (R1 and R2), when R2 was found abusing R1. R1's care plan indicated placing him on every 15-minute checks or 1:1 observation when found having sexual activity. In addition, vital signs every 15 minutes when staff suspected alcohol use. R1's care plan was not developed for her schizophrenia (inability to think, manage emotions, and make appropriate decisions,) bipolar (personality shifts from depression or mania impeding ability to think clearly,) dependent personality disorder (need for others to care for her, trouble making decisions, and feeling helpless without support from others) and the Associated Clinical Psychology (ACP) assessment identified she had impaired insight, impaired judgment, and impulsivity. Findings include: R2's care plan dated 7/23/24, indicated he was a vulnerable adult related…

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 medications were administered in accordance with physician orders and failed to identify and report medication errors according to facility policy for 3 of 3 (R1, R2, R3) residents reviewed for medication administration. Findings include: R1 R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted on [DATE] with diagnoses including unspecified pain and had intact cognition. R1 received scheduled pain medication, received PRN (as needed) pain medication, and took opioid (a drug classification including some medications for pain relief) medication. R1's care plan included an alteration in comfort dated 10/13/24, with intervention of pain medication as ordered by MD (physician). R1's physician orders included an order for oxycodone HCl (oxycodone hydrochloride, an opioid drug used to treat moderate to severe pain) oral tablet 5 mg (milligrams) with start date 10/17/24 and discontinue date 11/6/24.…

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 inform a resident of the outcome of a grievance 1 of 1 resident (R3) who filed a grievance regarding concerns for another resident, R4. Findings include: R4's admission MDS dated [DATE], indicated she was rarely/never understood and identified severe cognitive impairment. R3's quarterly MDS dated [DATE], indicated she had intact cognition. Facility Grievance Summary dated 8/25/24, indicated R3 reported she placed her call light on because her roommate (R4) was moaning in pain. R3 reported the told the NA she thought R4 was having pain due to the moaning and stated the NA responded by saying, She can't talk. She's not in pain., and walked out of the room. The summary investigation indicated, nurse manager to get NA statement. The summary of findings indicated R4's roommate stated she was having pain and requested help. The NA stated the nurse came in and helped R4 right away. Summary of actions indicated, R4 was helped by the nurse. The administrator…

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 report allegations of verbal and emotional abuse immediately (within two hours) to the State Agency (SA) for 1 of 4 residents (R10) reviewed for abuse. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairment. On 6/28/24 a progress note written by the facility administrator indicated R10's family member (FM)-A was no longer allowed in the facility due to reports of staying overnights, threatening other residents, soliciting money from residents for hair services. The notes further indicated FM-A became irate, was seen in the main lobby shouting and pointing her finger, and ran up to R10 and shoved him in to a table whereby R10 fell backwards into a chair. Additionally, the note indicated FM-A grabbed R10 by both of his wrists, and left the facility with R10. FM-A proceeded to another resident and then took R10 to the street corner. The note indicate police were called and an officer…

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 identify in the facility assessment (FA) protocol related to the acuity for day-to-day operations and for emergencies for fifteen ventilator-dependent residents. Additionally, the facility failed to review the FA annually. Findings include: Review of the facility assessment tool dated 11/22/23, indicated the acuity of the residents was based upon the activities of daily living (ADLs) of each resident, whether the resident was independent, required the assistance of 1-2 staff, or was fully dependent upon staff for ADL assistance. Additionally, the FA identified resident mobility as a measure of acuity based upon whether the resident was independent, required an assistive device, or was, In a chair most of the time. The FA lacked ventilator-dependent residents in the consideration to determine resident acuity. On 7/17/24 at 11:28 a.m., during an interview the director of nursing (DON) acknowledged the FA lacked mention of the ventilator-dependent residents in the acuity section. The DON further stated the staffing for 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 perform a self-administration of medication assessment and obtain provider order to have medication left in room and self-administered for 1 of 1 (R46) resident reviewed for self-administration of medication. Findings included, R46's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R46 was cognitively intact. Diagnoses included renal insufficiency5 diabetes, and Asthma. R46's care plan undated, indicated R46 chose to self-administer Arnuity Ellipta Aerosol Powder Breath Activated 200 MCG/ACT (Fluticasone Furoate) and PRN Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA). All other medication would be administered by nursing. R46's Self Administration of Medication Evaluation form dated 5/25/23 indicated R46 was approved to self-administer inhalation meds-meds taken orally by breathing in the medication. R46's Order Summary dated 5/23/24 indicated an order written on 8/15/23 okayed R46 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 a physician was notified of elevated blood glucose results for 1 of 1 resident (R20) reviewed who had specific physician's orders with parameters for physician notification of high blood glucose results. Findings Include: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 was cognitively intact, did not exhibit rejection of care during the assessment period, and diagnosis included diabetes mellitus and peripheral vascular disease. R20 also received insulin seven days during the assessment period. R20's care plan printed 5/22/24, indicated a focus for potential for alteration in blood sugar related to diagnosis of diabetes with history of refusing blood sugar checks, and medications. Goals included R20's blood sugar would be maintained between 60 and 120. Interventions included resident and family education provided and to monitor resident for signs/symptoms of hyperglycemia and hypoglycemia. R20's face sheet…

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 homelike environment for 1 of 1 residents (R65) reviewed who had enteral feeding liquid spilled on the bottom of the tube feeding pump pole and on the floor. Findings include: R65's significant change Minimum Data Set, dated [DATE], included R65 was severely cognitively impaired, dependent on staff for all activities of daily living, had a diagnosis of traumatic brain injury, and indicated they had a feeding tube through which they received more than 50% of their nutrition. During observation and interview on 5/20/24 at 2:13 p.m., R65 was lying in bed in their room with tube feeding running and their representative present. The tube feeding pump was attached to a pole, the base of which was covered in more than 50 drips of tube feeding liquid nutrition. The floor under the base of the pole had an area approximately12 inches by 6 inches covered in tube feeding liquid. R65's representative stated the tube feeding mess bothered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to develop a comprehensive resident-centered care plan with resident-specific target symptom monitoring and resident-specific interventions for 1 of 5 residents (R72) reviewed for unnecessary medications. Findings include: R72's quarterly Minimum Data Set (MDS) dated [DATE], indicated R72 had an absence of spoken words, was rarely or never understood, and sometimes understood others. MDS indicated R72 was dependent on staff for all activities of daily living (ADLs). MDS indicated R72 had non-traumatic brain dysfunction, respiratory failure with a tracheostomy (a surgical airway created in the windpipe as an alternative method for breathing), and depression. R72's MDS indicated she had no hallucinations, no delusions and had exhibited no verbal or physical behaviors. R72's MDS indicated she received an antidepressant medication. R72's Care Area Assessment (CAA) for cognitive loss and dementia dated 10/24/23, indicated she had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review the facility failed to ensure diagnostic standards of practice were followed for 1 of 1 resident (R24) who was newly diagnosed with schizophrenia. Findings include: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) guidelines dated 2013, identified to be diagnosed with schizophrenia, a person must have two or more of the following symptoms occurring persistently in the context of reduced functioning: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Additionally, continuous symptoms should have persisted for at least six months including one month of active phase symptoms listed above. The National Alliance on Mental Illness (NAMI) schizophrenia information page dated 2024, identified although schizophrenia could occur at any age, the average age of onset tended to be in the late teens to the early 20s for men, and the late 20s to early 30s for women. It was uncommon for schizophrenia 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 a resident's preferred activities for individual entertainment were available for 1 of 2 residents (R64) reviewed for activities. Findings include: R64's annual Minimum Data Set (MDS) dated [DATE], identified he was rarely/never understood. No behaviors or rejection of care occurred. Diagnoses included traumatic brain injury and respiratory failure. The family interview identified it was very important to listen to preferred music and do preferred activities. R64's communication Care Area Assessment (CAA) dated 10/30/23, identified R64 rarely understood and had not spoken or used gestures due to a brain injury. R64 may have been able to hear staff voices but was not able to respond. R64's quarterly MDS dated [DATE], identified no behaviors or rejection of care. R64 was totally dependent on staff for all activities of daily living. R64's care plan dated 9/15/23, identified there was an alteration in socialization and potential 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 ensure blood thinner medications were held per provider order for 1 of 1 resident (R65), and failed to implement a physician order for 1 of 1 resident (R57) related to a rash. Findings include: R65's significant change Minimum Data Set, dated [DATE], included R65 was severely cognitively impaired, dependent on staff for all activities of daily living, and had diagnoses of traumatic brain injury due to a gunshot to the chest and subsequent cardiac arrest, seizure disorder, muscle spasms, myoclonus (quick, jerky uncontrollable movements), convulsions, tracheostomy, anxiety, and depression. The MDS indicated R65 took an anticoagulant (blood thinner) medication. R65's care plan dated 3/21/24, included they took a blood thinner to prevent blood clots and indicated they were at increased risk of bruising and bleeding complications due to medication use. The care plan instructed staff to administer medication as ordered. R65's pain focus…

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 was positioned appropriately with the head of the bed (HOB) at 30-45° (degrees) or higher during and after medication administration via gastric tube, failed to label tube feeding nutrition when started, and failed to replace a tube feeding administration set daily for 1 of 1 residents (R65) reviewed for tube feeding. Findings include: R65's significant change Minimum Data Set, dated [DATE], included R65 was severely cognitively impaired, dependent on staff for all activities of daily living, and had diagnoses of traumatic brain injury, seizure disorder, muscle spasms, myoclonus (quick, jerky uncontrollable movements), convulsions, tracheostomy, anxiety, and depression. The MDS indicated they had a feeding tube through which they received more than 50% (percent) of their nutrition. R65's Hospitalist Discharge summary dated [DATE], indicated R65 was hospitalized with vomiting, fever, and gastroparesis (a condition where…

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 assistance and coordination of services to ensure timely referral and treatment for prosthetic fit for 1 of 1 resident (R37) reviewed who needed a prosthesis. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], included R37 was cognitively intact, had a limb prosthesis, required maximal assistance for lower body dressing, putting on footwear, standing, and transfers, and had diagnoses of diabetes, depression, heart failure, tracheostomy, and severe morbid obesity. R37 received 2 days of occupational therapy (OT) and 15 minutes of physical therapy (PT) in the previous 7 days. R37's care plan dated 10/20/23, included R37 had an alteration with transfers related to right BKA (below the knee amputation). The care plan indicated R37 would like to improve her transfer abilities as much as possible and instructed staff to ensure resident has prosthetic on prior to any transfer. R37's provider progress notes 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 interview and document review, the facility failed to ensure gradual dose reductions (GDR) were attempted, or an adequate medical justification for the use of psychotropic medications for 1 of 5 residents (R42) reviewed for unnecessary medications. Findings include: R42's annual Minimum Data Set (MDS) dated 42/24, indicated no cognitive impairment and no reports of feeling down, depressed, or hopeless. R42's MDS indicated he did not experience any hallucinations or delusions, did not reject care, and did not exhibit any verbal or physical behaviors. The MDS indicated R42's diagnoses included depression, and respiratory failure with a tracheostomy (a surgical airway created in the windpipe as an alternative method for breathing). Furthermore, R42's MDS indicated he was taking an antipsychotic on a routine basis and no GDR had been attempted. A GDR is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to adhere to infection control evidence based practices for a resident urinary catheter bag being placed on the floor for 1 of 1 resident (R72) reviewed for infection prevention and control practices. Findings include: R72's quarterly MDS dated [DATE], indicated R72 had an absence of spoken words, was rarely or never understood, and sometimes understood others. MDS indicated R72 was dependent on staff for all activities of daily living (ADLs) and had an indwelling catheter. MDS indicated R72 had non-traumatic brain dysfunction, chronic respiratory failure with a tracheostomy, and had Extended-Spectrum Beta Lactamase (ESBL) resistance (ESBL are found in some bacteria that cannot be killed by many types of antibiotics used to treat infections). R72's CAA for communication dated 10/24/23, indicated she had impaired ability to express herself due to her tracheostomy and mechanical ventilation, caused by myasthenia gravis (a chronic weakening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 2 of 5 residents (R24, R52) reviewed for immunizations were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC Pneumococcal Vaccine Timing for Adults dated 3/15/23, indicated adults aged 65 years and older who have had no prior pneumococcal vaccinations could either have option A which indicated PCV20, or option B, give PCV15 and follow with PPSV23 after at least one year of giving PCV15. If only the PPSV23 vaccination was administered prior at any age, option A indicated PCV20 could be administered after 1 year or option B indicated PCV15 could be administered after 1 year. If only the PCV13 vaccination was administered at any age, option A indicated PCV20 could be administered after 1 year, or PPSV23. If PCV13 was administered at any age, and PPSV23 was administered prior to [AGE] years of age, option A indicated PCV20 could be administered after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to report allegations of verbal and emotional abuse immediately (within two hours) to the State Agency for 1 of 4 residents (R1) reviewed for abuse. Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) on 10/23/23 at 3:30 p.m. indicated on 10/22/23, at 6:00 a.m., a verbal altercation between R1 and cook (CK)-A occurred in which CK-A spoke to R1 in a derogatory manner and, Screamed at other residents in front of everyone. The facility report was filed 10/23/23 at 5:40 p.m. and indicated staff first knew about the incident on 10/23/23 at 3:30 p.m., when in fact staff was told on 10/22/23 at 11:00 a.m. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact. R1's progress notes lacked information on allegations of abuse. On 10/27/23 at 12:55 p.m. R1 stated, [CK-A] came out of the kitchen because she was mad at me. She called me called me a [derogatory name], said she bet I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review the facility failed to perform skin assessments for 3 of 3 residents (R25, R37, R45) and failed to obtain physician ordered weights to monitor for weight loss for 2 of 4 residents (R29, R79) reviewed for quality of care. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 was moderately cognitively impaired and required extensive, one-person physical assistance with bed mobility and transfers. The MDS indicated R25 was at risk for skin breakdown. R25's diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, schizophrenia, bipolar disorder, insomnia, and diabetes. R25's care plan dated 3/15/23, indicated R25 was at risk for skin breakdown due to incontinence and refusing showers. The care plan instructed staff to monitor skin for irritation and breakdown during cares and weekly skin assessments. R25's skin assessment dated [DATE], indicated, Resident has redness on both legs and on the groin. No skin issue noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to maintain a clean and sanitary condition of the walk-in cooler, kitchen equipment, and kitchen floor to promote sanitation in the kitchen. This had the potential to affect 75 residents receiving food from the kitchen. Findings include: During the initial kitchen tour on 4/24/23 at 11:45 a.m., the walk-in cooler was observed. Upon entering, the floor was noted to be sticky. There was red jelly like substance on the floor near the shelves. The floor was scattered with food crumbs and debris. Upon the top shelf the following was observed; Heinz brand yellow mustard lid was loose with dried yellow drippings down the side of the container, [NAME] brand thousand island dressing had the cover partially in place with dried flaky drippings down the container onto the shelf, and [NAME] brand cottage cheese was covered, but chunks of cottage cheese was spilt down the side of the container. Upon observation of the prep and cooking area food debris,…

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 identify multidrug resistant organism (MDRO) in 4 of 4 residents (R6, R12, R53, R68) reviewed for infections. The facility also failed to ensure proper personal protective equipment (PPE) was utilized for 1 of 1 residents (R68) reviewed for PPE. Furthermore, the facility failed to ensure current standards of practice for glove use and handwashing were being followed for 1 of 1 resident (R24), when staff provided personal care. Findings include: Tracking R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 had moderate cognitive impairment and diagnoses of respiratory failure and had a tracheostomy (surgical airway placed in neck to aid in breathing). R6's hospital transfer orders dated 2/28/23, indicated R6 was colonized (bacteria is present in body without active infection) for Methicillin resistant staphylococcus aureus [(MRSA) a MDRO] and had a history of active MRSA pneumonia. R12's annual MDS dated [DATE], indicated R12…

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 the resident and determine safety for self-administration of medications (SAM) for 1 of 1 (R25) resident who was observed to have prescribed nicotine replacement gum at the bedside. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 was moderately cognitively impaired and required set up help for locomotion and eating, and extensive, one-person physical assistance with most other activities of daily living (ADL)s. R25's diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, schizophrenia, bipolar disorder, insomnia, and diabetes. R25's care plan dated 3/15/23, identified R25 was currently independent with smoking at this facility and instructed staff to complete a smoking evaluation quarterly and as needed. R25's care plan further identified R25 had history of suicidal ideation. The CP lacked evidencen R25 was assessed for SAM. R25's physician orders indicated 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 notify the physician timely of a change of condition (COC) for 1 of 1 (R92) resident reviewed for hospitalization. Findings include: R92's admission Minimum Data Set (MDS) dated [DATE], identified moderately cognitively impaired per staff interview. R92 had no rejection of care. R92 required extensive assist with activities of daily living (ADLs) except required only supervision for walking in room. R92's diagnoses included debility related to cardiorespiratory conditions and respiratory failure. R92 required tracheostomy care and a ventilator. R92's admission Care Area Assessment (CAA) dated 2/23/23, identified R92 triggered for cognition. Resident interview was unable to be completed due to hospitalization. Per the staff interview R92's memory was okay and resident recognized staff members, knew the location of her room and that she resided in a nursing home. R92's care plan dated 3/20/23, identified R92 was alert and oriented times three (x 3 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, observation, and document review, the facility failed to ensure resident room walls were in good repair to create a home-like environment for 3 of 4 residents (R9, R79, and R88) reviewed for room environment. Findings include: R9's admission Record form indicated R9 was his own representative. R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated R9 had intact cognition. During interview and observation 4/25/23 at 9:31 a.m., R9's walls in his room contained scuff marks and R9 stated the marks on the walls bothered him. During interview and observation 4/27/23 at 9:31 a.m., nursing assistant (NA)-G verified the marks on the walls in R9's room and stated she would not want marks like that on her walls and the resident's rooms were supposed to be home-like and residents reported it bothered them. R79's admission MDS dated [DATE], indicated it was very important to R79 to take care of personal belongings or things. R79's significant change MDS dated [DATE], indicated R79 had intact…

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 discharge Minimum Data Set (MDS) was completed for`1 of 2(R30) residents who discharged from the facility. Findings include: R30's admission MDS dated [DATE], indicated R30 was cognitively intact and had diagnoses of seizures and hypertension. R30's nursing progress note dated 11/7/22 at 4:25 p.m., indicated R30 discharged home with family. R30's medical record lacked evidence a discharge MDS was completed. When interviewed on 4/27/23 at 3:05 p.m., registered nurse (RN)-H verified a discharge MDS assessment for R30 was not completed. RN-H stated she was not sure if the discharge was unplanned and therefore not communicated to her. RN-H acknowledged the MDS was missed and further stated the assessment should have been completed in 14 days. When interviewed on 4/27/23, at 3:53 p.m. the Director of Nursing (DON) expected all MDS assessments to be completed on time. A facility policy for MDS assessments was not available.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure completed Minimum Data Set (MDS) assessments were accurate for 3 of 3 residents (R12, R25, R68) reviewed for resident assessment. Findings include: R12's annual MDS dated [DATE], indicated R12 was cognitively intact and had diagnoses of respiratory failure and had a tracheostomy. R12's MDS further indicated he had a current MDRO. R12's provider note dated 12/29/22, indicated R12 had a history of MRSA infection, but had no current MRSA infection. R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 was moderately cognitively impaired and required set up help for locomotion and eating, and extensive, one-person physical assistance with most other activities of daily living (ADL)s. The MDS indicated R25 had no broken or loosely fitting full or partial denture. R25's diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, schizophrenia, bipolar disorder, insomnia, and diabetes. R25's annual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was conducted, documented and retained to ensure mental health needs were appropriately addressed or provided for 1 of 3 resident (R28) reviewed for PASARR. Findings include: R28's Medical Diagnosis form indicated diagnoses of schizophrenia and anxiety identified on 6/15/22, and post traumatic stress disorder (PTSD) identified on 7/18/22. R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 was not evaluated by Level II PASARR. R28's significant change MDS dated [DATE], indicated intact cognition, was independent for most activities of daily living (ADLs), and had a diagnoses of anxiety, schizophrenia, and PTSD. R28's Initial Pre-admission Screening (PAS) Results dated 12/2/21, outlined a section labeled Mental Illness which concluded, Based on the information provided for this nursing home stay, it appears this person meets the criteria for MI (mental illness) 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 ensure routine personal hygiene was completed and provided for 1 of 1 resident (R52) reviewed for nail care. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated impaired cognition, did not reject care, and required extensive assistance for personal hygiene and most activities of daily living (ADLs). R52's Medical Diagnosis form indicated the following diagnoses: memory deficit following cerebrovascular disease (a condition that affects blood flow to the brain) and type 2 diabetes mellitus. R52's care plan dated 6/27/22, indicated R52 had a self care deficit and an intervention included, Assist with personal hygiene A1 [assist of one] with personal hygiene, A2 [assist of two] with check and change. A bath schedule located at the nursing station indicated R52 received baths a.m. on Mondays. During observation on 4/24/23 at 12:22 p.m., R52 was in a hospital gown and had brown debris under various fingernails.…

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 therapeutic diet that took into account a residents clinical condition for 1 of 1 resident (R79) Findings include: R79's significant change minimum data set (MDS) dated [DATE] indicated intact cognition, did not reject cares, required set up help for eating, and had a diagnosis of unspecified protein calorie malnutrition. muscle wasting and atrophy to multiple sites, and a fracture of the mandible (a facial bone attached to muscles involved in chewing and other mouth movements). R79's Profile form in the electronic medical record (EMR) indicated R79 was admitted [DATE]. R79's Clinical Physician Orders form dated 2/15/23 indicated a regular diet, mechanical soft texture, (a diet designed for people who have trouble chewing and swallowing) and regular thin consistency diet for malnutrition. R79's care plan dated 2/17/23 indicated history of inadequate oral intakes related to poor appetite following a mandibular fracture as…

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 implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R40) resident reviewed who had post-traumatic stress disorder (PTSD). Findings include: R40's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, required supervision with most activities of daily living (ADLs). Diagnoses included PTSD, mood disorder, and major depressive disorder. R40's care plan dated 7/8/22, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization related to PTSD. R40's Associated Clinic of Psychology (ACP) note dated 9/13/22, identified diagnosis of PTSD resulting from being a victim of assault. During interview on, 4/24/23 at 2:14 p.m., R40 confirmed she had a diagnosis of PTSD and depression. R40 stated her depression kicks in every once and a while when she misses her kids and grandkids…

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 consulting pharmacist (CP) identified or acted upon 1 of 1 resident (R53) reviewed for long term antibiotic use. Furthermore, the facility failed to ensure CP recommendations were addressed or acted upon for 1 of 5 residents (R25) reviewed for unnecessary medications. Findings include: R53 R53's admission MDS dated [DATE], indicated R53 had mild cognitive impairment and diagnoses of respiratory failure, kidney disease and a history of alcohol abuse. R53's provider order dated [DATE], indicated R53 required rifaximin (antibiotic) tablet 550 milligrams (mg) twice daily for pneumonia (respiratory infection). Furthermore, R53's rifaximin order had no stop date. R53's consultation pharmacist progress note dated [DATE] at 9:49 p.m., indicated no medication irregularities. R53's consultation pharmacist progress note dated [DATE] at 2:15 p.m., indicated no medication irregularities. When interviewed on [DATE] at 10:20 a.m., registered nurse (RN)-J…

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 track and monitor the appropriate use of antibiotics use for 1 of 1 residents (R53) reviewed for antibiotic use. Findings include: R53's admission MDS dated [DATE], indicated R53 had mild cognitive impairment and diagnoses of respiratory failure, kidney disease and a history of alcohol abuse. R53's provider order dated 2/17/23, indicated R53 required rifaximin (antibiotic) tablet 550 milligrams (mg) twice daily for pneumonia (respiratory infection). Furthermore, R53's rifaximin order had no stop date. R53's provider note dated 2/22/23, lacked indication of why R53 was on rifaximin. R53's provider note dated 3/22/23, lacked indication of why R53 was on rifaximin. The facility infection and antibiotic tracking logs dated 2/2023- 4/2023, lacked indication of R53's antibiotic use. When interviewed on 4/26/23 at 10:20 a.m., registered nurse (RN)-J stated R53 was not being treated for any current infection. RN-J had not realized R53 had been on an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure residents' call lights were functioning for 1 of 1 resident (R52) reviewed for call lights. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE] indicated cognitive impairment, and required extensive assistance with most activities of daily living (ADLs). R52's Medical Diagnosis form indicated the following diagnoses: diabetes mellitus, memory deficit following cerebrovascular disease (a condition affecting blood vessels in the brain), complete traumatic amputation of left lower leg. R52's care plan revised 3/21/23 indicated R52 was at risk for falls related to confusion, recent left above the knee amputation, blindness in the left eye, and a cataract in the right eye which included an intervention to keep the call-light within reach. During observation on 4/24/23 at 12:22 p.m., R52's call light device was in the on position, however, the light above R52's room was not lit up. During observation on 4/24/23 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 maintain sanitary equipment for 2 of 2 residents (R6, R14) reviewed for environmental cleanliness. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 had moderate cognitive impairment and diagnoses of respiratory failure and had a tracheostomy (surgical airway placed in neck to aid in breathing). R6's MDS further indicated R6 required tube feeding for nutrition. An observation on 4/24/23 at 5:35 p.m., R6's tube feeding pump was not running. The pump had multiple splattered light brown dried substance on it. There was also splattered light brown substances on the legs of the pole the pump was attached to. An observation on 4/26/23 at 7:11 a.m., R6's IV pump was infusing. The same spattered light brown substances remained splattered on the pump and pole. When interviewed at 4/26/23 at 7:46 a.m., registered nurse (RN)-I verified the dried substance on R6's pump and stated it was likely tube feeding formula…

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.