Fair Oaks Lodge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. R3's MDS also identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an activities of daily living (ADL) self-care performance deficit related to immobility and related to amputation of one lower extremity. R3 required assistance of one for toilet use, personal hygiene, dressing and bathing. During observation on 2/12/25 at 7:37 a.m. nursing assistant (NA)-F, wearing a gown and gloves, was assisting R3 while in bed 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 document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R26) who utilized an indwelling catheter. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified cognitive portion of the MDS was not completed. Identified R26 had diagnoses which included Alzheimer, neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), and benign prostatic hyperplasia (BPH) (enlarged prostate). MDS lacked information regarding R26's indwelling catheter. R26's annual Care Area Assessment (CAA) dated 9/11/24, identified R16 required required extensive assistance with toileting. Indicated R7 had an indwelling catheter related to urinary retention (unable to completely empty the bladder) and BPH. R26's care plan revised 4/1/24, identified R26 had an indwelling catheter due to urinary retention. Care plan identified catheter bag should have been covered…

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 complete and comprehensive assessment was completed for 1 of 1 residents (R16) reviewed for braces. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], identified R16 had severe cognitive impact and diagnoses which included anxiety, depression and end stage renal disease (ESRD) (loss of kidney function). Identified R16 required extensive assist with activities of daily living (ADL's) which included toileting, transfers, and dressing. R16's face sheet identified R16 had a diagnosis of Parkinson's disease (disease of the nervous system). R16's care plan revised 11/14/24, indicated R25 had an ADL self-care performance deficit related to weakness. R16's goal was to receive staff assistance with ADLs. R16's care plan lacked information regarding R16's ankle-foot orthosis (AFO) brace (to support the ankle and keep the toes aligned with the rest of the foot). R16's care area assessment (CAA) dated 11/14/24, indicated…

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 accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R26) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024, identified Section . C 0100: to C 0500 Should Brief Interview for Mental Status Be Conducted? SECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. Section H 0100: Appliances Item Rationale Health-related Quality of Life It is important to know what appliances are in use and the history and rationale for such use. Code this section if an indwelling catheter including a supra pubic catheter is used. R26's quarterly Minimum Data Set (MDS)…

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 follow the comprehensive care plan for 1 of 1 residents (R37) whose care plan was reviewed. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and had diagnoses which included: Alzheimer's disease, dementia, anxiety and was currently receiving hospice services. R37 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and eating. R37's care plan revised 11/15/24, indicated R37 had an altered nutritional status related to dementia with a history of vascular dementia. R37 was to have soft cut up foods and pureed foods when needed. R37's intervention included: R37 was to have supervision when eating and staff were to encourage R37 to eat in the dining room sitting upright in R37's wheelchair. Review of R37 [NAME] undated, indicated R37 was a level four pureed, heart healthy diet and R37 required supervision with eating.…

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 oral cares were performed for 1 of 3 residents (R42) who required assistance with hygiene, and were reviewed for activities of daily living (ADL). Findings Include: R42's admission Minimum Data Set (MDS) dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. R42's Care Area Assessment (CAA) dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. Identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. R42's interventions included personal hygiene/oral care assist of one. During an interview on 2/10/25 at 1:15 p.m., R42 indicated staff had never…

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 meaningful and engaging activities for 1 of 1 residents (R37) reviewed for activities. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and had diagnoses which included Alzheimer's disease, dementia, anxiety and was currently receiving hospice services. R37 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R37's care area assessment (CAA) dated 9/16/24, indicated R37 had concerns with cognition and dementia. R36's CAA further indicated R36 did not communicate often and was not responding to conversations as much. R37's care plan revised 11/15/24, indicated R37 had a diagnosis of frontotemporal and vascular dementia with a history of alcoholism with limited R37's ability in leisure involvement. R37's goals were to maintain leisure abilities by actively engaging in structured leisure…

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 to ensure hearing aids were available to maintain hearing/communication needs for 1 of 1 resident (R3) reviewed for hearing. Findings Include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. Identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. Identified R3 had moderate difficulty with hearing, and used hearing aide or other hearing appliance. R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an activities of daily living (ADL)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement a system to ensure medications were available to administer as ordered for 1 of 1 residents (R14) identified who did not receive medications as ordered. Findings include: R14's admission Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition and diagnoses which included: hypertension (elevated blood pressure), neurogenic bladder ( a condition where people lack bladder control due to a brain, spinal cord or nerve problem), and constipation. During an observation on 2/11/25 at 8:29 a.m., registered nurse (RN)-A set up R14's medications. RN-A indicated R14 was to receive Myrbetriq ( medication for overactive bladder ) and Psyllium ( medication for constipation) however neither med was available to administer, and had not been available for several days so she would have to contact pharmacy to order it again. R14's current Order Summary sheet dated 2/4/25, included the following: -Myrbetriq 50 mg oral tablet, take one tablet…

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 had a 6.25% percent medication error rate for 1 of 7 residents (R14) observed during medication administration. Findings include: R14's admission Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition and diagnoses which included: hypertension (elevated blood pressure), neurogenic bladder ( a condition where people lack bladder control due to a brain, spinal cord or nerve problem), and constipation. R14's current Order Summary sheet dated 2/4/25. included the following: -Myrbetriq 50 mg oral tablet, take one tablet daily for kidney stone. -Psyllium 0.52 mg capsule, take 2 capsules daily for constipation. During an observation on 2/11/25 at 8:29 a.m., registered nurse (RN)-A set up R14's medications. RN-A indicated R14 was to receive Myrbetriq( medication for overactive bladder ) and Psyllium ( medication for constipation) however neither med was available to administer, so she would have to contact pharmacy to order it again.…

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 3 of 5 residents (R5, R44, and R46) were offered or received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations. Finding include: Review of the current CDC recommendations 10/26//24, revealed The CDC identified Adults [AGE] years of age or older received the ( PCV13) at any age and who have received the PPSV23 before the age of 65 and had not received the Pneumo 20-valent conjugate Vaccine (PCV20) should receive a dose of the PCV 20 or the PCV21 five years after the most recent PPSV23 or PCV13 vaccine. Review of R5's facesheet identified R5, age [AGE] was admitted tot he facility on 1/13/25. Review of R5's Minnesota Immunization Information Connection (MIIC) record undated, identified R16 received the PPSV23 on 1/18/2011, and the PCV13 on 2/5/2019. R5's medical record lacked evidence R5 had been offered the PCV20 or PCV21 five…

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 dignity was maintained for 1 of 3 residents (R1) who had unwanted facial hair present, reviewed for dignity. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, and had diagnoses which included: hypertension, diabetes mellitus, respiratory failure, and fracture in past six months. Indicated R1 was dependent on staff for transfers, dressing and personal hygiene, which included shaving. R1's Care Area Assessment (CAA) dated 12/20/24, identified R1 had an activities of daily living (ADL) self-care performance deficit related to (r/t) collapsed vertebra, and was working with therapy. Indicated R1's care plan for self-care deficit and impaired physical mobility would be completed. Staff would assist with ADL completion and encourage self-participation. R1's care plan revised 12/30/24, identified R1 had an ADL self-care performance deficit related to collapsed vertebra. R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to ensure an allegation of employee to resident abuse was immediately reported no later than two hours, to the State agency (SA) for 1 of 3 residents (R4) reviewed for abuse. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had severe cognitive impairment and diagnoses which included: Alzheimer's disease, anxiety and depression. R4's MDS indicated R4 had no behaviors and was dependent on staff for transfers, eating, dressing and personal hygiene. R4's Care Area Assessment (CAA) dated 9/30/24, identified R4 had severe cognitive impairment and was unable to follow a conversation and answer appropriately. R4 had signs of short term memory, and was unable to recall what a daily object was such as a shirt, television, bed or colors. R4 attempted to hit staff while they were doing cares. Staff were unable to redirect R4 when R4 had these behaviors. R4's care plan revised 1/2/25, identified R4 had an activities of 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 submit to the State Agency (SA) the results of the investigation within 5 working days for 1 of 3 residents (R4) reviewed for abuse, for 1 of 1 allegations of abuse reviewed. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had severe cognitive impairment and diagnoses which included: Alzheimer's disease, anxiety and depression. Indicated R4 had no behaviors and was dependent on staff for transfers, eating, dressing and personal hygiene. R4's Care Area Assessment (CAA) dated 9/30/24, identified R4 had severe cognitive impairment and was unable to follow a conversation and answer appropriately. R4 had signs of short term memory, and was unable to recall what a daily object was such as a shirt, television, bed or colors. R4 attempted to hit staff while they were completing cares. Staff were unable to redirect R4 when R4 had these behaviors. R4's care plan revised 1/2/25, identified R4 had an activities of daily living…

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 call light was within reach for 1 of 4 residents (R3) reviewed for call light accessibility. Findings Include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact, and had diagnoses which include: anxiety, depression, and asthma (a condition that affects airways and makes breathing difficult). Indicated R3 was dependent on staff for rolling left and right, transfers, dressing and hygiene. R3's Care Area Assessment (CAA) dated 8/23/24, identified R3 had chronic pain related to low back pain, neuropathy (condition that affects the nerves outside brain and spinal cord) and history of fusion of lumbosacral region ( surgical joining of vertebrae to the lower back area of spine). R3 took Lyrica (medication used to treat nerve pain) for pain management. R3's care plan revised 10/3/24, identified R3 had an activities of daily living (ADL) self-care performance deficit and limited physical…

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 adequate supervision was provided for 1 of 3 residents (R2) reviewed, who required supervision while eating due to assessed choking risk. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2's diagnoses included epilepsy, hemiplegia and hemiparesis following cerebrovascular disease, and no cognitive impairment. Further, MDS revealed R2 did not have any swallowing concerns but was assessed to require a mechanically altered diet. R2's care plan dated 5/30/24, indicated R2 had potential for altered nutritional status and required Level 6 Soft and Bite Sized diet texture, and R2 was independent with eating however required to eat in the dining room as she needed to be supervised. R2's Risks vs Benefits document dated 6/26/24, indicated R2 had a risk of having swallowing issues related to diagnosis of hemiplegia and hemiparesis. R2 had minimal teeth that made it hard to properly chew food all the way.…

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 the residents received the prescribed diet, as ordered, for 1 of 2 residents (R2) reviewed for mechanically altered diets. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2's diagnoses included epilepsy, hemiplegia and hemiparesis following cerebrovascular disease, and R2 had no cognitive impairment. Further, MDS revealed R2 did not have any swallowing concerns but required a mechanically altered diet. R2's Order Summary Report dated 8/14/24, indicated R2 required a regular diet, level 6 soft and bite sized texture, thin liquid consistency and directed staff to add fluid to foods and add salt to foods as or 5/29/24. Review of International Dysphasia Diet Standardization Initiative (IDDSI) dated 01/19, indicated Level 6 Soft and Bite-Sized for adults consisted of soft, tender and moist, ability to bite off a piece of food is not required, ability to chew bite sized pieces so that they are safe 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 appropriate hand hygiene was performed while assisting with toileting cares for 1 of 1 residents (R3) reviewed. Findings include: R3's significant change Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included fusion of spine and reflex neuropathic bladder. R3's care plan dated 8/2/24, indicated R3 required assist of one staff for toileting and personal hygiene needs. On 8/14/24 at 2:39 p.m., nursing assistant (NA)-B and NA-C knocked and entered R3's room. R3 was sitting on the commode and was hooked up to the mechanical sit to stand lift. NA-B and NA-C applied gloves, NA-C got out wipes and assisted R3 with toileting hygiene cares. NA-C tossed the wipes into the garbage can and NA-B assisted with pulling up R3's brief and pants. NA-C continued to wear the same gloves and grabs R3's wheelchair, touched the mechanical lift, grabbed the garbage, and touched the doorknob. NA-C was stopped by surveyor prior 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 monitor for healing and complete neuro checks for 1 of 3 residents (R1), who rolled off the bed and sustained a scalp hematoma and traumatic hematoma of forehead. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included obstructive hydrocephalus (a neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the ventricles (cavities) deep within the brain), morbid obesity, and epilepsy. R1's care plan revised on 3/21/22, indicated R1 had impaired mobility related to obstructive hydrocephalus, history of epilepsy, major depressive disorder, anxiety disorder, diabetes, morbid obesity, pain, muscle weakness, and inability to walk. Additionally, R1's Care Plan indicated she was at risk for bleeding and excessive bruising related to anticoagulant therapy related to immobility and sedentary lifestyle has history of deep vein thrombosis and embolism with interventions listed…

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 follow plan of care for bed mobility and incontinence cares for 1 of 3 residents (R1) reviewed for accidents, when R1 rolled off the bed and sustained a scalp hematoma and traumatic hematoma of forehead and was sent to the emergency department (ED) for a CT scan with negative results. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included obstructive hydrocephalus (a neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the ventricles (cavities) deep within the brain), morbid obesity, and epilepsy. R1's care plan revised on 3/21/22, indicated R1 had impaired mobility related to obstructive hydrocephalus, history of epilepsy, major depressive disorder, anxiety disorder, diabetes, morbid obesity, pain, muscle weakness, and inability to walk. Further, R1's care plan identified R1 as Limited physical mobility with interventions listed as: does not ambulate; bed…

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 follow enhanced barrier precautions while providing high contact direct care for 1 of 2 (R1) residents reviewed. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of extended spectrum beta lactamase (EBSL) resistance (enzymes that confer resistance to most beta-lactam antibiotics, including penicillin, cephalosporins, and the monobactam aztreonam). R1's care plan revised on 3/21/22, indicated R1 had impaired mobility related to obstructive hydrocephalus, history of epilepsy, major depressive disorder, anxiety disorder, diabetes, morbid obesity, pain, muscle weakness, and inability to walk. Further, R1's care plan identified R1 required assist of two staff for bed mobility and toileting. However, R1's care plan lacked evidence of R1 requiring enhanced barrier precautions. On 7/9/24 at 12:56 p.m., R1's door was closed with a sign posted outside of the door indicating R1 required enhanced…

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 food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to ensure dishes were sanitized when dishwashing temps were not reaching the required temperatures. Further, the facility failed to ensure staff were wearing proper hair restraints such as hair and beard nets and ensure safe delivery of beverages during dining observation. This deficient practice had the potential to affect all 45 residents who received food and beverages from the refrigerators and freezers. Findings include: On 6/24/24 at 11:23 a.m., during the initial tour of the kitchen area with the dietary manager (DM) the following concerns were identified: Walk in produce cooler: - 1/3 container of opened buttermilk with an expiration date of 6/6/24. -1/3 large container of poppyseed dressing with an opened date of 12/23/23. -1/2 large container of ranch dressing without notation of an open date. - jar of opened pickles belonging to staff without a notation…

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 provide mandatory training on the facility specific QAPI (Quality Assurance and Performance Improvement) program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. Findings include: Review of facility's New Employee Orientation Guide, Relias Training Essentials part 1 through 4, and Nursing and Rehab Employee Handbook dated 1/22, lacked documentation on QAPI training for employees. During an interview on 6/27/2024 at 1:02 p.m., nursing assistant (NA)-D indicated she did not know what QAPI was. During an interview on 6/27/2024 at 1:09 p.m., licensed practical nurse (LPN)-A confirmed she did not know what QAPI was or what it stood for. LPN-A indicated the facility used to have a big board and a group of people would get together to review falls however the facility had got away from doing that anymore. LPN-A stated only…

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 store tube feeding and suctioning supplies in a clean and sanitary manner for 1 of 1 residents (R7) whose supplies were left sitting out. In addition, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated R7 was mildly cognitively impaired and had diagnoses which included depression, chronic obstructive pulmonary disease (COPD) (COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), quadriplegia (paralysis of both arms and both legs), and epilepsy (disorder that causes seizures). Identified R7 was totally dependent on staff for all transfers, activities of daily living (ADLs), and personal hygiene. During an observation on 6/24/24 at 4:31 p.m., R7 was currently hospitalized as of 6/20/24. R7 shared a room with another resident and R7's items were in the back of the room. R7's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R34) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R34's admission Minimum Data Set (MDS) dated [DATE], identified R34 had moderate cognitive impairment and had diagnosis which included acute respiratory failure, Chronic obstructive pulmonary disease (COPD), (a chronic inflammatory lung disease that causes obstructed airflow from the lungs, and hypertension (elevated blood pressure). R34's care plan identified R34 had an activity of daily living (ADL) self-care performance deficit related to immobility and weakness. R34's care plan interventions included dependence on staff for bathing, dressing, and toileting. Identified R34 had a double below the knee amputation (BNA). Care plan lacked interventions related to self medication administration. R34's Order Summary Report signed…

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 adequate supervision was provided, an accurate assessment was completed and smoking interventions were implemented to reduce the risk of avoidable injuries for 1 of 1 resident (R4) who reviewed for smoking. Findings include: R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment and had diagnoses which included: dementia, psychotic disturbance, and muscle weakness. R4 was dependant on staff for supervision of bed mobility and transfers. R4's MDS also indicated R4 did not refuse cares or services. R4's significant change Care Area Assessment (CAA) worksheet dated 4/4/24, indicated R4 had complications of immobility and a history of paranoia and hallucinations. R4's care plan dated 4/12/24, identified R4 was not safe to smoke unsupervised. Care plan indicated R4 would be directly supervised (accompany the resident outside and remain with them) for the entire duration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure administration of tube feeding formula according to physician's orders for 1 of 1 residents (R43) reviewed for tube feeding. Findings include: R43's admission Minimum Data Set (MDS) dated [DATE], indicated R43 was cognitively intact and had diagnoses which included cancer and diabetes. Identified R43 received tube feedings due to coughing/choking during meals and difficulty/pain when swallowing. Indicated R43 was independent with transfers and required set-up assistance with personal hygiene. R43's admission Care Area Assessment (CAA) dated 4/30/24, indicated R43 had a Jejunostomy (J) Tube (a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine for supplemental feeding, hydration or medicine). and required tube feeding as a nutritional approach. Identified R43 had swallowing problems, cancer, and a recent decline in functional abilities. R43's care plan dated 6/6/24, indicated R43…

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 oxygen therapy as ordered by the physician for 1 of 1 resident (R14) who utilized oxygen to maintain adequate oxygen saturation levels. Findings include: R14's significant change Minimum Data Set (MDS) dated [DATE], indicated R14 was cognitively intact and had diagnoses which included depression, chronic obstructive pulmonary disease (COPD) (COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and respiratory failure. R14's care area assessment (CAA) dated 5/25/24, indicated R14 had respiratory disease and required maximum assistance with activities of daily living (ADLs). The CAA lacked documentation R14 was to receive continuous oxygen therapy. R14's signed physicians orders dated 5/24/24, indicated R4 was to receive continuous oxygen therapy via nasal cannula (NC) at 2 liters (L) during all shifts to keep saturation levels above 90%. R14's care plan, revised 3/25/24, indicated R14 had…

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 personal laundry was transported in a manner that prevented risk of contamination for 1 of 5 hallways observed for linen transportation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. During an observation on 6/25/24 at 9:08 a.m., nursing assistant (NA)-B was walking down the hall carrying soiled bed linen with her bare hands against her clothing, dropped a soiled pillowcase on the floor and bent down with her bare hands and picked the pillowcase off the floor and proceeded to place the soiled linen in a cart in the soiled utility room and performed hand hygiene. During an interview on 6/25/24 at 9:11 a.m., NA-B confirmed she had carried soiled bed linen which contained urine with her bare hands against her clothing from R34's room. NA-B stated she should…

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 received the prescribed diets as ordered for 3 or 3 residents (R1, R4 and R7) reviewed for therapeutic diets. Findings include: R1's admission record dated 4/12/24, indicated R1 had diagnoses of stroke with hemiplegia (paralysis of one side of the body) affecting right dominate side, diabetes, and dysphagia (problems swallowing). R1's hospital discharge orders dated 4/12/24, indicated R1 had a percutaneous endoscopic gastrostomy (PEG) tube with water flushes twice daily at 2:30 p.m. and 8:00 p.m. R1's diet was pureed (4) with moderately thick liquids and thickened Ensure plus supplements three times daily. R1's nutritional care plan directed the following: -A diet texture of Level 4- pureed, start date of 4/12/24, -Provide assistance (specify), start date of 4/15/24, -Fluids- Level 3 moderately thick (honey), start date 4/12/24 -Follow swallow guideline (specify), start date 4/12/24 During an interview on 4/25/24 at 11:22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for 3 of 3 residents (R1, R2, R3) reviewed. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of displaced comminuted fracture of shaft of right tibia and had a surgical wound. R1's April Medication Administration Record (MAR) revealed an order for monitor skin alteration/wound and document status of wound in progress notes every shift and identified R1's wound as right lower extremity, which was marked as completed by staff on the MAR every shift from 4/1/24 through 4/10/24, however R1's medical record lacked evidence of progress notes every shift on the status of R1's wound. R1's record did not identify any wound treatment orders for her right lower extremity. R1's Progress Note from Orthopedics appointment dated 4/3/24, indicated R1's right lower extremity incisions are…

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 R19's responsible party was notified of a change of condition in a timely manner for 1 of 1 residents (R19) reviewed for change of condition who developed symptoms of short of breath (SOB), abnormal lung sounds, low oxygen saturations and was transferred to the emergency room (ER). Finding include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 had severe cognitive impairment and had diagnoses which included dementia, Parkinson's Disease and seizure disorder. Identified R19 required extensive assistance of two for bed mobility, transfers, dressing, toileting and personal hygiene. Review of R19's progress notes dated 3/15/23 to 9/27/23, revealed the following: - 5/17/23, at 12:41 p.m. R19 had an emesis after lunch. - 5/17/23, at 1:49 p.m. R19 had wheezy lung sounds and oxygen saturations of 90% on room air. - 5/18/23, at 9:19 a.m. R19 continued to have wheezy lung sounds and was short of breath which required the use of 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 observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 2 residents( R18) reviewed for activities of daily living (ADL)'s. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and had diagnosis which included hypertension, (elevated blood pressure), Parkinson's Disease, and non Alzheimer dementia. Identified R18 required one person physical assist from staff with personal hygiene. R18's current care plan dated 8/3/22, indicated R18 had deficits with ADL's related to Parkinson's disease and dementia. R18 required staff assistance with personal hygiene. R18's comprehensive Care Area assessment dated [DATE], identified R18 required assistance with ADL's. Indicated R18 had an activity intolerance related to Parkinson's disease and dementia. During an observation on 9/25/23 at 12:40 p.m., R18 was lying in bed and had several gray 1/4 inch long facial hairs on her chin and above her…

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 3 of 5 residents (R1, R2, R26) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Pneumococcal Vaccine Timing for Adults, dated 3/15/2023, from the CDC identified adults [AGE] years of age or older who had previously received the PCV13 and one or more doses of the PPSV23 should receive one dose of PCV20. The dose of PCV20 should be administered at least one year after the most recent dose of PPSV23. Review of R1's Minnesota Immunization Information Connection (MIIC) identified R1 had received the PCV13 11/21/16 and two PPSV23 vaccinations on 1/5/1998 and 10/11/2017. R1's medical record lacked documentation R1 had been offered or received the PCV20 vaccination. Review of R2's MIIC identified R2 had received the PCV13 vaccination on 10/25/2017 and two PPSV23 vaccinations on 10/1/2008 and 10/1/2010 R2's medical record lacked documentation R2…

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.