Good Samaritan Society - Waconia And Westview Acre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice by not following provider-ordered edema management interventions, including assistance with application and removal of compression stockings, and by inaccurately documenting care on the Treatment Administration Record (TAR) for 1 of 3 residents (R25) reviewed for edema management.Findings include:R25's admission Minimum Data Set (MDS), dated [DATE], identified R25 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R25's diagnoses included non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), muscle weakness (reduced strength), abnormalities of gait and mobility (difficulty walking), hypertension (high blood pressure), arthritis (joint inflammation causing pain), and insomnia (difficulty sleeping). Review of R25's physician orders, dated 3/4/26, indicated an order 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 record review the facility failed to ensure ongoing monitoring of pressure ulcers for 2 of 4 residents (R2 and R15) reviewed for pressure ulcers. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. F686 Based on observation, interview, and record review the facility failed to ensure ongoing monitoring of pressure ulcers for 3 of 4 residents (R2, R15 and R 72) reviewed for pressure ulcers. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) guidelines dated 2016, identified a pressure ulcer as, . localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. These are then staged according to the following criteria: - Stage I Pressure Injury: Non-blanchable erythema (redness) of intact skin. - Stage…

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 record review and interview, the facility failed to ensure effective communication of necessary clinical information to the dialysis center for 1 of 1 resident (R88) reviewed for dialysis services.Findings include:R88's admission Minimum Data Set (MDS), dated [DATE], identified R88 had intact cognition and required assistance with activities of daily living (ADLs). R88's diagnoses included dependence on renal dialysis (requires routine dialysis treatment to perform kidney function), chronic kidney disease stage 5 (severe kidney failure where the kidneys no longer function adequately), and presence of other vascular implants and grafts (surgically placed devices or vessels used to support blood flow, often for dialysis access). Review of R88's electronic medical record (EMR) indicated R88 received routine dialysis treatments at an external dialysis center on a scheduled basis (Mondays, Wednesdays, and Fridays). Review of facility documentation, including dialysis communication forms and transfer 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 record review and interview, the facility failed to ensure a trauma-informed care approach was implemented by not completing a trauma assessment upon admission for 1 of 1 resident (R10) reviewed for trauma-informed care.Findings include:R10R10's admission Minimum Data Set (MDS), dated [DATE], identified R10 had intact cognition and required assistance with activities of daily living (ADLs). R10's diagnoses included post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing or witnessing a traumatic event), anxiety disorder (excessive worry), and depression (persistent feelings of sadness). Review of R10's electronic medical record (EMR) lacked evidence a trauma assessment was completed upon admission to identify past trauma, triggers, or individualized care needs related to trauma history. Review of R10's comprehensive care plan, print date 3/26/26, did not include trauma-informed interventions, approaches to minimize triggers, or strategies to promote emotional 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 record review and interview, the facility failed to act upon consultant pharmacist recommendations in a timely manner related to completion of an Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 3 residents (R11) reviewed for unnecessary medications.Findings include:R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder causing changes in thinking, movement, and behavior), non-Alzheimer's dementia (decline in memory and thinking not caused by Alzheimer's disease), and depression (persistent sadness or loss of interest). The MDS indicated R11 received antipsychotic medication. R11's physician order summary report, dated 3/4/26, included an order for Quetiapine (an antipsychotic medication used to treat mood and thought disorders) 25 milligrams (mg) to be administered at bedtime for repeated episodes…

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 establish and implement an infection prevention and control program to prevent the spread of infection by not initiating Enhanced Barrier Precautions (EBP) per Centers for Disease Control (CDC) guidance. when indicated and failing to ensure staff followed EBP during resident care for 3 of 6 residents reviewed for infection control (R11, R46, and R88).Findings include: Review of CDC guidelines dated 8/12/22, identified EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. CDC guidelines updated 6/28/24 identified examples of indwelling medical devices include, but are not limited to, central vascular catheters (including…

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 revise the care plan to include current behaviors for 1 of 1 residents (R51), toileting needs for 1 of 1 residents (R20), discontinued medications for 1 of 1 residents (R24), resident receiving tube feedings for 1 of 1 residents (R7), and falls for 1 of 1 residents (R55) in the sample whose care plans were reviewed. Findings include: R51's Face Sheet printed 5/27/25, indicated the diagnoses of Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, restlessness and agitation. R51's admission minimum data set (MDS) dated [DATE], identified R50 was cognitively impaired and required extensive assistance with activities of daily living. During observation and interview on 5/18/25 at 4:24 p.m., it was observed that R51 had long finger nails on all fingers and thumbs. Some of which were 1/4 inched in length. R51 was also noted to have been unshaven, noting a rechargeble razor on resident's bed. R51 stated, I was meaning to cut them…

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 pillows were not used in a manner to restrain residents while in bed for 1 of 1 resident (R21) reviewed for restraints. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified R21 had moderate cognitive impairment and diagnoses of dementia, Parkinson's, seizure disorder and depression. MDS also indicated R21 did not use any restraints. R21's care plan reviewed 5/27/25, identified R21 had limited physical mobility and was a fall risk related to confusion and restlessness. Staff were directed to assist R21 from lying to sitting and from sitting to lying with an assist of one to help guide lower extremities and to assist R21 with an assist of two for sit to stand for all transfer. R21 used a fall mat next to his bed. R21's care plan did not identify the use of pillows under his fitted sheet to prevent R21 from crawling out of bed. During an observation on 5/18/25 at 5:20 p.m., R21 was lying on his back in…

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 pharmacy consultant (PharmD) gradual dose reduction (GDR) recommendation was communicated to the Hospice prescriber for 1 of 5 residents (R43) reviewed for unnecessary medications. Findings include: In review of R43's Order Summary Report (print date 5/27/25) indicated the diagnoses of: dementia, visual hallucinations, psychotic disturbance, mood disturbance and anxiety. R43's quarterly Minimum Data Set (MDS), dated [DATE], identified R43 had severely cognitive impairment. R43 was admitted to Allina Hospice with the diagnosis of vascular dementia [due to] CVA (cerebral vascular accident - stroke) on 1/29/25, with the orders to use hospice agency standing orders. In review of R43's Order Recap Report (printed 5/20/25) resident was and is receiving Quetiapine Furmarate ( and anti-psychotic medication with the following order changes: The following orders were prescribed on the dates indicated to the facility: 3/26/25 Quetiapine Fumarate Oral…

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 incidents were reported timely to the State agency (SA) for 2 of 4 residents (R213 and R214) whose incidents were reviewed. Findings include: R213's admission Minimum Data Set (MDS) dated [DATE], identified R213 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). Diagnoses included depression, anxiety, radiation sickness, lung cancer, breast cancer, thyrotoxicosis (a condition where there is too much thyroid hormone in the body), muscle weakness, metabolic encephalopathy (a condition where a change in brain function, like confusion or decreased consciousness, is caused by an underlying metabolic or chemical imbalance in the body), diabetes and acute kidney failure. R213's care plan revised 5/4/25, indicated R213 had potential to develop pressure sores related to impaired mobility and incontinence with an intervention instructing staff to reposition R213 from side to side when in bed every two 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 thoroughly investigate and protect residents from an allegation of neglect for 1 of 4 residents (R214) whose incidents were reviewed. Findings include: R214's discharge Minimum Data Set (MDS) dated [DATE], indicated R214 had intact cognition, and had diagnoses of hypertension (high blood pressure), atrial fibrillation (irregular heartbeat that originates in the heart's upper chambers), anemia (low red blood cells) and depression. A report was received by the SA, dated 5/1/25 at 12:59 p.m., which indicated R214 was seen in the clinic last week (4/22/25) for a visit after R214 was discharged from the transitional care unit (TCU) at facility. According to the report, R214 had been in and out of the facility twice prior to her being seen in clinic. R214 brought all her medications with her from home to her appointment and it was then discovered there were two bubble medication cards that had medications missing and a few remaining labeled with another…

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 Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning for 2 of 2 residents (R49 and R59) reviewed for MDS accuracy. Findings include: R49's quarterly MDS dated [DATE], indicated under Section J (J1700-B) Falls documented R49 did not have any falls since the last MDS Assessment (admission MDS, submitted 1/14/25). In review of R49's electronic medical record (EMR), it was noted R49 had two falls since admission: 2/2/25 - R49 rolled out of bed and onto the floor 2/4/25 - R49 self transferred from wheel chair and fell to the floor During an interview on 5/21/25 at 10:33 a.m., nurse manager (RN)-A and interim director of nursing (DON)-A stated R49's two falls should have been documented on the 4/10/25 quarterly MDS. R59's Discharge Return Not Anticipated MDS submission dated 3/6/25, indicated under Section A (A2105) Discharge Status documented R59 was discharge 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 notify the county (designated state mental health authority) when 1 of 3 residents (R2) had a new on-set of mental illness. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). R2's admission record printed 5/18/25, indicated R2 had diagnoses of unspecified dementia with effective date of 10/1/22, psychotic disorder with delusions effective date 2/10/22, adjustment disorder with mixed anxiety and depressed mood effective date 3/10/22. R2's current, undated medication administration record (MAR) identified R2 had an antipsychotic medication, Haloperidol 0.5 milligrams (mg) every two hours as needed for agitation, delusions, or psychosis. R2's care plan revised 11/27/23, identified R2 had mood and behavior problems related to major depression, psychosis, recent history of hallucinations and delusion, verbally rude, angry…

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 complete and implement a baseline care plan within 48 hours of admission for 3 of 5 residents (R35. R41 and R215) reviewed for care plans. Findings include: R35's admission Minimum Data Set (MDS) dated [DATE], identified R35 had intact cognition and required assistance with all activities of daily living (ADLs). R35's diagnoses included end stage renal disease, heart failure, hypertension, cirrhosis, diabetes mellitus, arthritis, depression, dependence on renal dialysis, and chronic pain. R35's electronic health record (EHR) indicated R35 was admitted to the facility on [DATE]. EHR lacked evidence a baseline care plan had been initiated within 48 hours of admission. EHR indicated baseline care plan was developed on 4/18/25 and indicated R35 was dependent on staff for transfers, toileting and grooming/bathing. R41's admission MDS dated [DATE], identified R41 had moderate cognitive impairment and required assistance with ADL's. R41's 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 interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R35) reviewed for dialysis. Findings include: R35's admission Minimum Data Set (MDS) dated [DATE], identified R35 had intact cognition and required assistance with all activities of daily living (ADLs). R35's diagnoses included end stage renal disease, heart failure, hypertension, cirrhosis, diabetes mellitus, arthritis, depression, dependence on renal dialysis, and chronic pain. R35's physician orders, print date of 5/21/25, indicated an order for dialysis on Monday/Wednesday/Friday at Fresenius Waconia with a start date of 4/15/25. R35's care plan, print date of 5/21/25, failed to include dialysis including goals of treatment, and interventions allowing the nurse to assess the intervention's outcome and potentially revise care based on the resident's status. During interview on 5/27/25 at 3:49…

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 as needed (PRN) medications were administered per physician's order for 1 of 1 resident (R20) reviewed for edema. Findings include: R41's admission Minimum Data Set (MDS) dated [DATE], identified R41 had moderate cognitive impairment and required assistance with activities of daily living (ADL)'s. R41's diagnoses included acute on chronic systolic (Congestive) heart failure, atrial fibrillation, coronary artery disease, heart failure, hypertension, renal failure, localized edema, presence of prosthetic heart valve, and presence of coronary angioplasty implant and graft R41's physician orders with print date of 5/19/25, indicated R41 had an order for daily weights in the morning for heart failure with reduced ejection fraction (HFrEF) and to update physician assistant (PA) or medical doctor (MD) if increased of three pounds in a day or five pounds in a week. R41 also had an order for Torsemide 20 milligrams (mg) as needed (PRN) for HFrEF daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to comprehensively assess and develop interventions to address falls for 1 of 1 residents (R55) identified to have repeated falls. Findings include: R55's admission minimum data set (MDS) dated [DATE], indicated R55 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADLs). R55's fall care area assessment (CAA) dated 4/13/25, indicated R55 had no recent falls. R55 was a fall risk due to wandering behavior, impaired cognition, and was new admission. R55's face sheet printed 5/18/25, indicated R55 had dementia, macular degeneration (progressive eye disease, gradually leads to loss of central vision), repeated falls, congestive heart failure, spinal fusion and difficulty walking. R55's care plan revised 5/2/25, indicated R55 had an actual fall with no injury related to forgetfulness and not wearing proper footwear. Care plan interventions directed staff to ensure R55 was wearing gripper socks if he was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations for as needed (PRN) anti-psychotic medications were acted upon and addressed in a timely manner for 1 of 5 residents (R43) reviewed for unnecessary medication use. Findings include: In review of R43's Order Summary Report (print date 5/27/25) indicated the diagnoses of: dementia, visual hallucinations, psychotic disturbance, mood disturbance and anxiety. R43's quarterly Minimum Data Set (MDS), dated [DATE], identified R43 had severe cognitive impairment. R43 was admitted to Allina Hospice with the diagnosis of vascular dementia [due to] CVA (cerebral vascular accident - stroke) on 1/29/25, with the orders to use hospice agency standing orders. In review of R43's Order Recap Report (printed 5/20/25) resident was and is receiving Quetiapine Furmarate ( and anti-psychotic medication with the following order changes: 3/26/25 Quetiapine Fumarate Oral Tablet 50 milligrams (mg) (Quetiapine Fumarate) Give 100 mg…

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 orthostatic blood pressure monitoring was completed for 1 of 5 residents (R55) reviewed for unnecessary medication use and who consumed antipsychotic medication on a routine basis. In addition, the facility failed to routinely assess residents who received antipsychotic medications for signs and symptoms of tardive dyskinesia (disorder that results in involuntary repetitive body movements) for 1 of 5 residents (R215) reviewed for unnecessary medications. Findings include: R55's admission minimum data set (MDS) dated [DATE], identified R55 had moderate cognitive impairment, required extenisve assistance with activities of daily living (ADLs)., and consumed antipsychotic medications on a daily basis. R55's care plan revised 4/18/25, indicated R55 was on antipsychotic medication therapy related to anxiety with interventions of monitor resident condition based on clinical practice guidelines or clinical standards and consult 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper hand hygiene was performed during dining services for 1 of 1 resident (R1) reviewed for assistance with meal set-up. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R1's diagnoses included hypertension, neurogenic bladder, diabetes mellitus, arthritis, cerebral palsy, epilepsy, atrial fibrillation and depression. During observation on 5/19/25 at 5:14 p.m., nursing assistant (NA)-D assisted R1 with applying ketchup to his bun. NA-D took individual ketchup packets from the middle of the table and removed the top of R1's hamburger bun off, applied ketchup and used the ketchup packet to spread the ketchup around and placed the top bun on pulled pork sandwich. NA-D did not sanitize hands before or after assisting R1 and did not wear gloves. During interview on 5/19/25 at 5:23 p.m., NA-D stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 2 of 6 residents (R20 and R49) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate. R20's admission minimum data set (MDS) dated [DATE], identified R20 as having the diagnoses of diabetes, thyroid disorder, anxiety and depression, and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess wounds with measurements and consistently implement interventions to promote healing of current pressure ulcers (PU) for 1 of 3 residents (R3). Findings include: R3's quarterly Minimum Data Set, dated [DATE] indicated severe cognitive impairment, required substantial assistance with footwear, had one unhealed Stage 3 PU (full thickness loss of skin) and at risk for developing more, and did not exhibit rejection of care behaviors. R3's care plan dated 2/10/25, indicated R3 had a Stage 3 pressure ulcer to her left lateral (outer side) ankle with interventions included provide pressure reducing mattress and pressure reducing cushion in wheelchair, notify nurse immediately of any new areas of skin breakdown, R3 had an activities of daily living (ADL) performance deficit with interventions included resident requires assistance of one staff apply surgical shoe on right foot and shoe on left foot. R3's care plan lacks…

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 ongoing, routine toenail care was provided to prevent potential foot-related complications for 1 of 3 residents (R1) reviewed who had long, unkept toenails. Findings include: R1's significant change minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses including multiple sclerosis and bilateral broken legs. R1's care plan dated 1/15/25 indicated R1 required assistance of one staff member for weekly bed baths. The care plan instructed weekly skin observation by licensed nurse and to keep fingernails short but did not address toenail care. R1's medical record was reviewed and lacked information on resident refusal of toenail care and any ongoing monitoring and/or treatments to ensure R1's toenails were cared for timely and on an ongoing basis to reduce her risk of foot-related complications secondary to long toenails. On 2/25/25 at 1:09 p.m., R1 was interviewed and stated staff clip her fingernails, but no…

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 comprehensive assessment of falls to include identifying a root cause and also failed to implement appropriate interventions to reduce the risk of falls for 2 of 3 residents (R2 and R4) reviewed for falls. Findings include: R2's quarterly minimum data set (MDS) dated [DATE] indicated intact cognition, no falls since the previous assessment and diagnoses included dementia and chronic obstructive pulmonary disease. R2's care plan dated 2/4/25 indicated R2 was at risk for falls related to weakness and shortness of breath with interventions of educate/instruct resident and family on usage of assistive devices added 10/15/23, remind resident not to bend over to pick up dropped items, encourage use of grabber or to ask for assistance added 10/15/23, and ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair added 10/15/23. The care plan also indicated R3 was independent with four wheeled walker 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.

Based on interview and document review, the facility failed to complete a thorough investigation for 2 of 3 residents (R5, R9) who reported concerns related to quality of care. Findings include: Facility investigation indicated the director of nursing (DON) was notified via email on 9/16/24 at 4:24 p.m., from administrative assistant (AA)-D the facility had two bad apples working there. The document included handwritten notes dated 9/18/24 at 11:50 a.m., listing licensed practical nurse (LPN)-B and nursing assistant (NA)-A had not completed nightly rounds and refused to complete requested cares stating the next shift could complete them. Further, the document indicated R5's name dated 9/18/24 at 12:10 p.m. Information listed included LPN-B and NA-A had laughed when he reported he had chest pain, had not followed up on the report with any assessment or monitoring, and they had spoke to him and other residents in a condescending or argumentative way. Facility investigation lacked evidence other residents and other staff were interviewed about the identified concerns. Facility…

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

Based on observation and interview, the facility failed to consistently administer medication in the time frame allotted (one hour before and after assigned time) for 1 of 2 residents, (R2), reviewed for receiving a combination medication used for treatment of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Findings include: R2's admission Minimum Data Set (MDS) indicated R2 was cognitively intact and was able to communicate needs and identify preferences. The MDS identified R2 had a medically complex condition. R2's MDS identified medical diagnoses, which included arthritis due to other bacteria, sepsis (infection of the bloodstream) due to methicillin susceptible staphylococcus aureus (MRSA-a type of infection which is resistant to many antibiotics), a cerebrovascular accident (CVA-stroke), and Parkinson's disease. A review of R2's medication administration record for September of 2024 indicated R2 was to receive Sinemet (Carbidopa-Levodopa-a medication used in…

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

Based on observation, interview, and document review, the facility failed to ensure 3 of 4 kitchen fans were free of lint buildup and cleaned on a regular schedule. This had the potential to affect all the residents, staff, and visitors who consumed food from the main kitchen. Findings Include: During observation in the main kitchen on 8/14/24 at 9:21 a.m., fan #1 was attached near a corner of a wall, approximately 7 ½ feet off the ground, and slightly angled down. This fan moved air into the dish return and cleaning area. Fan #2 was attached near a corner of a wall, approximately 7 ½ feet off the ground, and slight angled down. This fan moved air by one refrigerator, one freezer, and into the steam tray holding area. Fan #3 was attached on a wall, approximately 7 ½ feet off the ground, and angled down. This fan blew into the kitchen prep zone which also includes the fryer, steamers, and mixer. All three fans had lint build up on the wire guard (shroud that protects the fan blades). This build up was noticeable on the front and rear portions with multiple strands of lint,…

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 wheelchairs in a clean and sanitary manner for 2 of 2 residents (R20 and R15) reviewed for safe, clean, comfortable, and home-like environment and for 1 of 1 resident (R31) reviewed who had enteral feeding liquid spilled on the tube feeding (TF) pump and support legs of the pole. Findings include: R20's facesheet printed on 8/15/24, included diagnoses of cerebral hemorrhage (a type of stroke that causes bleeding in the brain), Parkinsonism (movements associated with Parkinson's disease such as stiffness and tremor) and arthritis. R20's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 required substantial assistance with most activities of daily living (ADL), except eating in which she was independent with set-up help. R20 did not walk and utilized a manual wheelchair. R20's care plan, printed 8/15/24, did not address…

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 administrative staff and State Agency (SA) were notified immediately but no later than 2 hours of an allegation of abuse for 1 of 1 residents (R5) who reported abusive cares during toileting cares provided by staff. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 did not present any inattention, disorganized thinking, or altered level of consciousness. The MDS indicated R5 had moderately impaired cognitive skills for decision making regarding tasks of daily life and there were short- and long-term memory problems, according to staff interview. The MDS also indicated R5 required substantial to maximal assistance from a staff helper with toileting hygiene and could be independent with personal hygiene. The MDS listed diagnoses of hemiplegia (paralysis on one side of the body) of the left side, high blood pressure, dementia (the loss of cognitive function, like thinking, remembering, and reasoning), anxiety,…

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 allegations of abuse and implement appropriate interventions for 1 of 1 residents (R5) reviewed for abuse allegations. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 did not present any inattention, disorganized thinking, or altered level of consciousness. The MDS indicated R5 had moderately impaired cognitive skills for decision making regarding tasks of daily life and there were short and long-term memory problems, according to staff interview. The MDS also indicated R5 required substantial to maximal assistance from a staff helper with toileting hygiene and could be independent with personal hygiene. The MDS listed diagnoses of hemiplegia (paralysis on one side of the body) of the left side, high blood pressure, dementia (the loss of cognitive function, like thinking, remembering, and reasoning), anxiety, depression, bipolar disorder, schizophrenia (mental health disorder that can affect 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 document review, the facility failed to ensure appropriate orthostatic blood pressure monitoring was in place for 1 of 5 residents (R5) reviewed for psychotropic medications; in addition, the facility failed to implement bowel movement (BM) protocol for 1 of 4 residents (r43) reviewed for constipation. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated there was no inattention, disorganized thinking, or altered level of consciousness present. The MDS indicated according to staff, R5 had moderately impaired cognitive skills for decision making regarding tasks of daily life and there were short and long-term memory problems. The MDS also indicated R5 required substantial to maximal assistance from a staff helper with toileting hygiene and could be independent with personal hygiene. The MDS listed diagnoses of hemiplegia (paralysis on one side of the body) of the left side, high blood pressure, dementia (the loss of cognitive function, like thinking, remembering,…

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 proper infection control practice for 1 of 2 residents (R17) reviewed for urinary catheter care. In addition, the facility failed to utilize enhanced barrier precautions (EBP) for 1 of 4 residents (R33) reviewed for infection control. Findings include: R17 R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 as cognitively intact, no rejection of care behaviors, dependent on most activities of daily living (ADL), and indicated an indwelling catheter. Diagnoses included neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), hyponatremia (low sodium levels), and multiple sclerosis (MS) (chronic disease of the central nervous system). R17's physician order dated 3/4/24, indicated R17 received Hiprex (antibiotic) tablet 1 gram by mouth two times a day for urinary anti-infective. R17's care plan (CP) dated 5/16/13 indicated, the resident has an Indwelling Catheter R/T MS, Neurogenic…

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.