St Anthony Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provided nail care for 1 of 4 residents (R15) reviewed for dependent activities of daily living (ADLs). Findings include: R15's PPS 5 day scheduled Minimum Data Set (MDS) assessment dated [DATE], included R15 was admitted [DATE] and had moderate cognitive impairment. R15 had impairment on one side and was dependent with bathing. Personal hygiene assessment was not recorded on the MDS submission. R15's undated care plan included a focus of being at risk for excessive bruising and bleeding due to use of coumadin (a blood thinner) with an intervention to remind R15 to use extra caution when shaving. The care plan included R15 had a self care deficit and required assistance with ADLs due to weakness, impaired mobility and having multiple disease processes and had an intervention of needing assistance with all ALDs. On 4/7/25 at 2:52 p.m., R15 was observed to have fingernails that extended past the tips of his fingers on both hands.…

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 current physician orders and parameters for 2 of 5 residents (R28, R61) reviewed for medications. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], included R28 had moderate cognitive impairment. R28 had diagnoses of gastroparesis (a disease of the digestive system), malnutrition, fecal impaction (a blockage of stool in the intestine). R28's last signed physician orders dated 3/4/25, included an order for prochiorperazine maleate (a medication to treat nausea and vomiting) 10 mg by mouth every 5 hours as needed for nausea and vomiting, polyethylene glycol (a medication to treat constipation) 17 grams by mouth one time a day, and metoprolol tartrate 25 mg by mouth twice a day with instructions to hold the medication if systolic blood pressure was less than 100. R28's medication administration record (MAR) for April included record of medication being given different than the most recent provider orders. Administration…

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 range of motion (ROM) exercises for 1 of 1 residents (R61) reviewed for mobility. Findings include: R61's significant change Minimum Data Set (MDS) dated [DATE], included diagnoses of neuromyelitis optica (inflammation of the nerves of the eye and spinal cord which may cause vision loss and muscle weakness), diabetes, encephalopathy (a disorder of the brain which may cause confusion, memory loss and personality changes). R61's MDS included she was dependent for dressing, eating and oral hygiene. R61's undated care plan, included R61 required assistance with activities of daily living (ADLs) due to impaired or decreased mobility, weakness and multiple disease processes. Interventions included to assist with positioning and mobility as needed. R61's care plan failed to include specific ROM exercises. R61's care conference note dated 3/19/25, included R61's family requested therapy for ROM due to stiffness. R61's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the consulting pharmacist (CP) failed to identify and report irregularities related to resident parameters for 2 of 2 residents (R28, R61) reviewed for physician ordered parameters. Findings Include: R28's quarterly Minimum Data Set (MDS) dated [DATE], included R28 had moderate cognitive impairment. R28 had diagnoses of gastroparesis (a disease of the digestive system), malnutrition, fecal impaction (a blockage of stool in the intestine). R28's last signed physician orders dated 3/4/25, included an order for metoprolol tartrate 25 milligrams (mg) by mouth twice a day with instructions to hold the medication if systolic blood pressure was less than 100. R28's medication administration record (MAR) for April included record of medication being given without documentation of blood pressure having been checked prior to administration. The order on the MAR included metoprolol tartrate 25 mg by mouth twice a day without instructions to hold the medication. R28's previous six…

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 thoroughly investigate an allegation of sexual abuse for 2 of 2 residents (R1 and R2) when they failed recognize the need to assess R1 for the ability to consent prior to the incident. Findings include: Review of the report to the State Agency (SA) indicated on 2/05/25, at 5:55 p.m. R1 and R2 were being sexually intimate in R1's room. Staff attempted to separate the two and have R2 go to his room. The report indicated the residents were closely monitored throughout the night to prevent further incident, investigation was initiated, and physician was updated. Review of the 5-day investigation report to the SA indicated on 2/12/25, R1 had BIM's of 4 which was severely cognitively impaired and R2 of 10 mild cognitive impairment both residents have not been deemed needing legal guardian and both make their own decisions with family input. In addition the investigation indicated both residents were seen by Associated Clinic of Psychology (ACP) who 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 ensure 1 of 2 resident (R1) was comprehensively assessed for their capacity to consent prior to engaging in sexual activity with R2. Findings include: Review of the report to the State Agency (SA) indicated on 2/05/25, at 5:55 p.m. R1 and R2 were being sexually intimate in R1's room. Staff attempted to separate the two and have R2 go to his room. The report indicated the residents were closely monitored throughout the night to prevent further incident, investigation was initiated, and physician was updated. Review of the 5-day investigation report to the SA indicated on 2/12/25, R1 had BIMMS of 4 which was severely cognitively impaired and R2 of 10 mild cognitive impairment both residents have not been deemed needing legal guardian and both make their own decisions with family input. In addition the investigation indicated both residents were seen by Associated Clinic of Psychology (ACP) who noted they were alert and oriented to family…

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 Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 3 of 3 residents (R3, R4 and R5) reviewed for hospitalization. This had the potential to affect all residents transferred to hospital. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's progress notes indicated R3 was hospitalized from [DATE] to 5/17/24. R3's record lacked evidence the Ombudsman for LTC was notified of R3's transfer to the hospital. R4's discharge Minimum Data Set (MDS) dated [DATE]/24, indicated diagnoses which included peripheral vascular disease or peripheral arterial disease (impaired circulation to the peripheral (distant arteries) of the hands and feet), methicillin resistant staphylococcus aureus (MRSA) (an antibiotic resistant organism) infection, pressure ulcer of unspecified joint, and local…

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 written notice of a bed hold upon transfer for hospitalization for 3 of 4 residents (R3, R4, and R5 ) reviewed for hospitalization. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's progress note dated 4/28/24 at 6:27 p.m., indicated licensed practical nurse (LPN)-A found R3's gastrostomy tube (G-tube) had been pulled out, the on-call nurse practitioner (NP) was contacted and ordered R3 to be transported to emergency department (ED) for G-tube replacement. LPN-A notified family member (FM)-B of the situation via phone. R3's progress note dated 4/28/24 at 9:42 p.m., indicated R3 was admitted to Hennepin County Medical Center hospital (HCMC) due to a fever and the need for further testing. R3's progress note dated 5/17/24 at 9:46 p.m., indicated R3 returned to the facility from HCMC on 5/17/24 at 5:28…

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 long term residents received routine physician visits (every 60 days) for 1 of 3 residents (R3) reviewed for routine physician care. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's clinical record indicated R3's physician completed routine physician visits on 2/5/24 and 5/22/24, greater than 60 days between visits. However, R3's clinical record lacked evidence a physician visit had been provided between 2/5/24 and 5/22/24. On 10/4/24 at 1:28 p.m., the administrator provided an email which contained the entire chart from the provider for R3. The provided chart indicated physician visits had been completed on 2/5/24 and 5/22/24, with no evidence of a physician visit within 60 days of 2/5/24. On 10/7/24 at 12:19 p.m., director of nursing (DON) and infection preventionist (IP) stated the medical records…

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 4 residents (R3, R9) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3's date of birth was 2/10/1948 ([AGE] years old), and diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were disposed of after expiration date and were properly stored, labeled, and dated. Furthermore, the facility failed to ensure refrigerated foods were disposed of after expiration on 1 of 4 resident fridges. This deficient practice had the potential to affect all 72 residents who recieve food from the kitchen. Findings include: During an observation on 3/4/24 at 6:21 p.m., the kitchen walk in refrigerator was reviewed. The following items were found to be expired and not to contain labels. -egg salad in a plastic container with plastic wrap covering had no date of when it was made. -a container of macaroni noodle salad with a mayonnaise dressing was made on 2/25/24 and was to be used by 3/1/24. -a container of cranberries was prepared on 2/25/24 and was to be used by 3/1/24. -a opened container of [NAME] heavy whipping cream had no open date however had a use by date of 3/3/24. During an observation on…

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

Based on interview and document review the facility Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement a corrective action plan related to repeat deficiencies regarding food storage, labeling and food safety. This had the potential to affect all 80 residents who resided at the facility. Findings Include: Review of the QAPI monthly and quarterly meeting minutes included the following data: The dietary director (DD) and registered dietician (RD) did not attend the following QAPI meetings, and the committee did not discuss issues regarding quality improvement plans regarding food storage, labeling and food safety in the kitchen: 4/18/23-DD and RD not in attendance; food storage, labeling and safety not discussed. 5/16/23- DD and RD not in attendance; food storage, labeling and safety not discussed. 6/20/23- DD and RD not in attendance; food storage, labeling and safety not discussed. 7/18/23- DD and RD not in attendance; food storage, labeling and safety not discussed. 8/15/23- DD and RD not in attendance; food storage, labeling and safety…

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 personal protection equipment (PPE) was used when sorting laundry. This had the potential to impact all 77 residents who reside in the facility. Furthermore, the facility failed to ensure resident ice packs were stored separately from resident food in 2 of 4 unit resident refrigerators. This had the potential to impact all 30 residents who reside on those units. The facility further failed to ensure proper glove usage and handwashing was implemented for 1 of 1 resident (R22) reviewed for personal cares. Laundry During an observation on 3/6/24 at 7:45 a.m., housekeeping assistant (HA)-B was observed in the laundry room. HA-B had gloves in place. HSK-A took a clear bag of dirty laundry from a laundry cart that was filled with several clear tied bags. Without donning an isolation gown, HA-B had opened the bag and sorted it into appropriate laundry carts. HA-B then obtained another clear bag from the same cart and without donning 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 interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 3 of 5 (R48, R66, R72) reviewed for vaccinations. Furthermore, the facility failed to ensure education and declination was obtained for declining the pneumococcal vaccination for 2 of 5 (R66, R72) residents reviewed for vaccinations. Findings include: The CDC identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult 65 years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R48's admission Minimum Data Set (MDS) dated [DATE], indicated R48 was [AGE] years old, had sever cognitive…

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 self administration of medication assessment (SAM) and physician's order to self administer medications was completed to allow residents to safely administer their own medications for 3 of 3 residents (R331, R45, R1) observed with medications at the bedside. In addition, the facility also failed to prevent 1 of 1 resident (R1) from self-administering water flushes via gastrostomy tube without a SAM assessment. Findings include: R331's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, did not have behaviors, did not reject cares, had complaints of difficulty or pain when swallowing, had coughing or choking during meals. R331's State Optional Assessment (SOA) dated 2/27/24, indicated R331 required extensive assist with bed mobility, transfers, and toileting, and limited assistance with eating. R331's Medical Diagnosis form indicated the following diagnoses: dysphagia following cerebral…

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 immediately report an injury of unknown cause to the administrator or State agency for 1 of 1 resident (R27) who was assessed to have a purple bruise to right side of back measured at 14 centimeters (cm) by 21 cm, reviewed for abuse. Findings Include: R27's significant change Minimum Data Set, dated [DATE], indicated R27 was cognitively impaired with limited range of motion to one upper extremity, impairment to both lower extremity and was dependent on staff for toileting. R27's vulnerable adult care plan updated 2/14/24, indicated staff were to assist R27 in removing self from dangerous, abusive situations. Assist R27 in reporting of abuse and neglect as appropriate. Staff were to investigate all signs, symptoms, or accusations as appropriate and provide a safe environment for R27. R27's face sheet printed 3/7/24, indicated diagnosis included alcoholic cirrhosis of liver with ascites (the increased pressure in the portal vein can cause fluid to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to develop a comprehensive care plan and develop and implement new interventions following a resident (R38) with a history of suicidal ideation and multiple suicide attempts reviewed for comprehensive care plan. Findings include: R38's significant change Minimum Data Set (MDS) dated [DATE], indicated R38 had moderately impaired cognition and diagnoses of post traumatic stress disorder (PTSD), bipolar disorder, major depressive disorder, acute stress reaction, and suicidal ideation. It further indicated R38 required substantial/maximal assistance with all activities of daily living (ADL) and mobility. R38's after visit summary dated 12/4/23, indicated R38 was seen on an emergency basis for depression and diagnosed with suicidal ideation. It also included a crisis stabalization plan (safety plan) to be used once R38 left the hospital and included the following: -warning signs of: feeling sad and arguing with her sister - coping strategies of: listening 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 residents were assisted with personal hygiene for 1 of 3 residents (R54) reviewed for activities of daily living who needed assistance from staff. Findings Include: R54's quarterly Minimum Data Set (MDS), dated [DATE], indicated R54 was cognitively intact, did not exhibit rejection of cares, and required supervision with toileting and dressing, R54's self care deficit care plan, revised 2/1/24, indicated status post right hip replacement impaired mobility and multiple disease process. Interventions included assist with activity of daily living (ADL), positioning and mobility as needed; provide guided maneuvering of extremities, verbal cueing and sufficient time for resident to perform and or assist during dressing and other ADL's as needed; extensive assist of 1 after incontinent episodes. R54's behavior careplan dated 11/24/23, indicated R54 was resistive to care often and interventions included allow R54 to make decisions,…

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 PICC (peripherally inserted central catheter) line dressing change was completed per standard practice for 1 of 1 resident (R181) reviewed for PICC lines. In addition, the facility failed to ensure an order was completed for a weight re-check on 1 of 1 resident (R57) reviewed for nutrition who had a 14.2 percent weight loss in one month. Further, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization that affected 1 of 1 resident (R47) reviewed for hospice services. Findings included: R181 R181's admission record printed 3/6/24, indicated R181 admitted to facility on 2/29/24 with diagnoses including bacterial infections, acute cystitis (bladder infection), acute embolism and thrombosis of left calf muscular vein (blood clot), type 2 diabetes mellitus, and morbid obesity. R181's admission evaluation (AE) dated 2/29/24, indicated R181 had mild cognitive impairment. The AE…

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 assess for and identify potential triggers for 1 of 1 resident (R38) who had a history of trauma. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated R38 had moderately impaired cognition and diagnoses of post traumatic stress disorder (PTSD), bipolar disorder, major depressive disorder, acute stress reaction, and suicidal ideation. It further indicated R38 had little interest or pleasure in doing things and feeling down, depressed or hopeless nearly every day in the look back period. Trouble falling/staying asleep or sleeping too much and trouble concentrating several days and thoughts of being better off dead or hurting herself, half or more of the days. R38's admission trauma screening dated 4/3/23, lacked notation of trauma history or potential triggers. R38's medical record lacked any additional trauma screenings. R38's mood and behavior care plan dated 10/25/23, indicated R38 sees on site psychology for behaviors…

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 monitor side effects for 2 of 2 residents (R32, R181) reviewed for anticoagulation (blood thinner) therapy. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, had a diagnosis of longstanding persistent atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart), and received anticoagulant therapy. R32's physician orders indicated R32 had an order on 3/1/22, for Eliquis (blood thinner) 5 milligrams take one tablet twice daily for atrial fibrillation. The orders lacked interventions for monitoring for side effects of taking the blood thinner. R32's care plan lacked interventions for monitoring for side effects of taking the blood thinner. R32's medical record lacked evidence R32 required monitoring for side effects of anticoagulation therapy. During interview on 3/7/24 at 8:31 a.m., trained medication aide (TMA) stated Eliquis was taken for pain and staff should watch 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 beverages were served in the appropriate consistency for 1 of 1 resident (R48) reviewed for therapeutic diets. Findings include: R48's admission Minimum Data Set (MDS) dated [DATE], indicated R48 had severe cognitive impairment, required assistance with eating, required a therapeutic and regular textured diet. R48's had diagnoses of vascular dementia, chronic kidney disease, degenerative disease of nervous system, and cognitive deficit. R48's nutrition care area assessment (CAA) dated 1/14/24, identified a functional problem that affected R48's ability to eat to include, Need for special diet or altered consistency which might not appeal to resident. R48's care plan dated 1/17/24, indicated R48 was at risk for altered nutrition and instructed staff to Provide, serve diet as ordered. R48's physician order dated 1/24/24, indicated per speech language pathology (SLP) recommendation, R48's diet changed to regular diet texture with…

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.