Warroad Care Center

Based on interview and document review, the facility failed to develop a policy and procedure defining the responsibilities of the medical director and ensure the medical director assisted in the implementation and guidance of resident care policies, and coordination of resident medical care in the facility. This had the potential to impact all 46 residents who resided in the nursing home at the time of the survey. Findings Include: During an extended survey, on 11/6/24, a medical director (MD) policy and the MD's job description and/or contract was requested; however, these items were not provided. During a telephone interview on 10/30/24 at 2:36 p.m., MD stated he was at the facility twice per month. Once to do residents rounds and the other was for paperwork; signing orders etc. The MD attended quality meetings as well. The MD was informed of staffing concerns; however, he was not in control of staff. The MD provided medical care to the residents, and he did review resident incident reports such as falls as well. During an interview on 11/6/24 at 2:18 p.m., the administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to develop and implement appropriate plans of action to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware. This had the potential to adversely affect all 46 residents residing in the facility. Findings include: See also F600: The facility failed to ensure 1 of 1 resident (R39) with known sexual behaviors towards others was comprehensively assessed and interventions implemented to mitigate risk to others and prevent ongoing sexual abuse for 2 of 2 residents (R31, R6) who were cognitively impaired and dependent on staff for their care and were sexually abused by R39. See also F689: The facility failed to ensure staff were following care planned interventions when transferring residents with a ceiling lift; and complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) to ensure resident and staff 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 interview, and document review, the facility failed to develop, monitor, and evaluate their identified performance measures. This had the potential to affect all 46 residents residing in the facility. Findings include: The February QAPI Education Report dated 3/8/24, identified staff education compliance was at 72.8%, however, the report failed to identify actions taken to increase compliance. The Quality and Safety Meeting (Quarter 1 Data) dated 4/15/24, identified the QAPI team reviewed the following topics: - Emerging infectious disease - Staff influenza vaccination program - Emergency preparedness - Environmental services - Minnesota Pollution Control Agency (MPCA) - Skilled nursing safety report (Casper, MDS, QIIP) - Safe resident handling - Consultant pharmacist report - PIP discussion. The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality and Safety Meeting (April Data) dated 5/20/24, identified the QAPI…

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 Standard Precautions: R99's admission MDS dated [DATE], identified R99 had moderate cognition and required intermittent catheterization. Diagnoses included neurogenic bladder, Alzheimer's disease, and dementia. R99's physician notes dated 10/17/24, identified R99 performed catheterization by himself as needed to empty his bladder. R99's care plan dated 10/22/24, failed to identify R99's catheterization plan and goals including what personal protective equipment was needed. R99's medication administration report (MAR) dated 10/1/24 through 10/31/24, identified staff were required to perform catheterization for R99 every shift or as requested by the resident due to the resident's neuromuscular dysfunction of the bladder. On 10/29/24 at 10:17 a.m., R99 was seated in a wheelchair in his room. R99 stated he used a catheter to empty his bladder due to being unable to urinate on his own. Staff used gloves but did not wear gowns when catheterizing him. On 10/30/24 at 1:30 p.m., registered nurse (RN)-A stated when…

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 assure employee infection control training and education was completed for 4 of 10 (LPN-A, LPN-B, RN-A, DON) staff reviewed for training and education.This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including: dementia care, abuse, resident rights, quality assurance, infection prevention, compliance and ethics, behavior health, and activities of daily living (ADLs). - Registered nurse (RN)-E completed education for resident rights 9/20/23, behavior health 8/3/23, and abuse 6/27/23, but had no further completed education. - Nursing assistant (NA)-I did not complete education regarding effective communication - NA-B completed no education in 2024. During an interview on 11/6/24 at 12:42 p.m., human resources (HR)-A stated she used to assign the annual staff education but registered nurse (RN)-C now assigned assigned the annual training for staff and presented…

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 ensure staff completed mandatory communication training for 4 of 10 staff (DON, RN-E, NA-B, NA-I) reviewed for training requirements. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) had not completed staff education including effective communication. - Registered nurse (RN)-E had not completed staff education including effective communication. - Nursing assistant (NA)-B had not completed staff education including effective communication. - NA-I had not completed staff education including effective communication. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including effective communication training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing…

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 ensure staff completed mandatory training for resident rights for 3 of 10 staff (DON, RN-E, NA-A) reviewed for training requirements. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) had not completed staff education including resident rights. - Registered nurse (RN)-E had not completed staff education including resident rights since 9/20/23. - Nursing assistant (NA)-I had not completed staff education including resident rights. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including resident rights training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing education transcripts when she started her role and did not have log in information until now…

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 facility specific abuse prevention training to 5 of 10 employees (DON, RN-E, LPN-C, NA-I, NA-B) reviewed for training. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including abuse. - Registered nurse (RN)-E last complete abuse training 6/27/23. - Licensed practical nurse (LPN)-C last completed abuse training 4/20/23. - Nursing assistant (NA)-I last completed abuse training 2/21/22. - NA-B completed no education in 2024. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including abuse, neglect, and exploitation training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing education transcripts when she…

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 Quality Assurance and Performance Improvement (QAPI) 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 for 5 of 10 employees (DON, RN-E, LPN-C, NA-B, NA-I) reviewed for training requirements. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including quality assurance. - Registered nurse (RN)-E did not complete staff education including quality assurance. - Licensed practical nurse (LPN)-C last completed quality assurance training 4/20/23. - Nursing assistant (NA)-B did not complete staff education including quality assurance - NA-I did not complete staff education including quality assurance During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible 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 record review the facility failed to ensure staff were educated on infection control policies and procedures for 4 of 10 staff (DON, RN-E, LPN-C,NA-B) who's training records were reviewed and 3 of 3 staff (NA-B, NA-C, LPN-A) who identified they were not educated in procedures for standard, transmission-based and enhanced barrier precautions (EBP). This had the potential to impact all 46 residents who reside in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including infection prevention. - Registered nurse (RN)-E did not complete infection prevention training. - Licensed practical nurse (LPN)-C last completed infection prevention education 4/20/23. - Nursing assistant (NA)-B completed no assigned staff education including infection prevention in 2024. During an interview on 10/29/24 at 10:17 a.m., NA-B was unable describe to differentiate between the different types of precautions and/or when to use them. During an interview on 10/29/24 at 12:23 p.m., NA-C…

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 ensure 4 of 10 staff (DON, RN-E, LPN-C, NA-B) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including compliance and ethics. - Registered nurse (RN)-E did not complete compliance and ethics training. - Licensed practical nurse (LPN)-C last completed compliance and ethics traninig 4/20/23. - Nursing assistant (NA)-B completed no assigned staff education including compliance and ethics in 2024. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including compliance and ethics training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff…

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

Based on interview and document review, the facility failed to ensure 12 hours of annual in-service training was completed for 2 of 5 nursing assistants (NA-A, NA-B) reviewed for in service requirements. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Nursing assistant (NA)-I did not complete 12 hours of continuing education. - NA-B did not complete 12 hours of continuing education. During an interview on 11/6/24 at 12:42 p.m., human resources (HR)-A stated she used to assign the annual staff education, but registered nurse (RN)-C assigned staff education now. RN-C assigned the annual training for staff and presented some of the general orientation education. The annual training was according to staff hire date: - NA-I: HR-A stated NA-I's hire dated was 6/27/23. NA-I had no specific dementia training at the time she transferred position from dietary to nursing. NA-I's last dementia training was in 2022. NA-I would have needed extra courses assigned to her that dietary 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.

Based on interview and document review, the facility failed to ensure 3 of 10 staff (DON, RN-E, NA-B) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including behavioral health. - Registered nurse (RN)-E last completed behavioral health training 8/3/23. - Nursing assistant (NA)-B completed no assigned staff education including behavioral health in 2024. During an interview on 11/6/24 at 12:42 p.m., human resources (HR)-A stated she used to assigned the annual staff education but registered nurse (RN)-C assigned staff education now. RN-C assigned the annual training for staff and presented some of the general orientation education. The annual training was according to staff hire date: - DON: HR-A stated the DON did not complete any of the new hire trainings. - RN-E: HR-A stated RN-E hire date was 8/29/13 and was past due for annual training.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide range of motion (ROM) services for 4 of 4 residents (R7, R19, R22 ,R43) reviewed for range of motion. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment. Diagnoses included multiple sclerosis (MS) (a potentially disabling disease of the brain and spinal cord that affects nerve fibers and causes communication problems), type 2 diabetes and peripheral vascular disease (PVD) (reduced blood flow to the arms and legs). R7 had a restorative nursing program (RNP) but R7 did not participate during the look back period. R7's care plan revised 8/9/24, identified R7 had a RNP. Restorative Therapy nursing assistant would monitor R7's progress and tolerance daily and document. RT staff were to report concerns to nursing and/or physical therapy/occupational therapy for assessment and recommendations. Staff were directed to provide: RT- UBC x15 mins (tension 90). Pulleys…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide toileting cares in a dignified manner for 1 of 1 resident (R12) reviewed for dignity. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 was severely cognitively impaired and R12 was dependent (helper performed all the effort and resident does none of the effort to complete the activity) for toileting and bed to chair transfers. R12 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. R12's care plan dated 8/9/24, identified R12 was cognitively impaired and required assist of two staff for ceiling lift transfers. During an interview on 10/28/24 at 2:38 p.m., R12 stated, last week, a nursing assistant left R12 in the bathroom in the ceiling lift alone. R12 was unable to say a name or date but R12 was crying and stated R12 waited at least 20 minutes. R12 was in the bathroom already in the lift, up in the air, and R12's feet were dangling and going numb. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed ensure a voiced grievance was acted upon; and provide a written policy for how the facility would handle grievances for 1 of 1 resident (R20) reviewed for missing property Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 was cognitively intact and demonstrated no delusional behavior and/or thinking. The facility 8/7/24, resident council minutes identified R20 was missing a long white, [NAME] nightgown that had been gone for an undetermined length of time. On 10/30/24 at 9:58 a.m., during a resident council discussion R20 stated she reported a missing night gown a few months ago at a resident council meeting. R20 stated she asked staff about the gown a couple weeks ago but had not received any follow up. An interview was completed on 10/30/24 at 2:45 PM, with environmental services manager (EVS) and laundry aide (LA)-A. LA-A stated in August 2024, the facility changed the laundry process, and all personal and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure allegations of potential sexual abuse were reported or timely reported to the administrator and state agency (SA) for 1 of 1 resident (R39) reviewed for abuse involving 2 of 2 residents (R6, R31) with cognitive impairment, who was observed inappropriately touching other residents' multiple times, Findings include: R6's quarterly MDS dated [DATE], identified R6 had moderate cognitive impairment and exhibited delusions, physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, verbal behaviors toward others four to six days per week and other behaviors not directed toward others four to six days per week. R6 required substantial assistance to dress and partial assistance with transfers. R6 was independent with ambulation once standing. Diagnoses included depression, anxiety, dementia, and sever mood disturbance. R31's quarterly MDS dated [DATE], identified R31 had severe cognitive impairment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide immediate protection and investigate allegations of resident-to-resident sexual abuse for 2 of 2 residents (R31, R6) reviewed for abuse, who were abused by R39. Findings include: R6's quarterly MDS dated [DATE], identified R6 had moderate cognitive impairment and exhibited delusions, physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, verbal behaviors toward others four to six days per week and other behaviors not directed toward others four to six days per week. R6 required substantial assistance to dress and partial assistance with transfers. R6 was independent with ambulation once standing. Diagnoses included depression, anxiety, dementia, and sever mood disturbance. R31's quarterly MDS dated [DATE], identified R31 had severe cognitive impairment and exhibited physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, and verbal…

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 accurate coding of the Minimum Data Set (MDS) for 1 of 3 residents (R7) reviewed for catheters. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had severely impaired cognition and an indwelling urinary catheter. Diagnoses included multiple sclerosis (MS), type 2 diabetes, and history of urinary tract infection (UTI). The MDS failed to identify R7 had a multi-drug resistant organism (MDRO). R7's care plan revised 8/9/24, identified R7 needed total assistance with toileting needs and catheter management. The care plan failed to identify R7 had an MDRO. R7's Physical Therapy Skilled Nursing Facility Treatment Note dated 9/12/24, identified R7 had an open wound on her right ischial tuberosity and had an increased risk of infection. Precautions/Restrictions: methicillin-resistant staphylococcus aureus (MRSA). During an interview on 10/30/24 at 10:06 a.m., the director of nursing (DON) stated staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a comprehensive care plan for 1 of 2 residents (R7, R99); and failed to involve family during the care conference and document the care conference fully for 1 of 2 residents (R7) reviewed for catheters. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had severely impaired cognition and an indwelling urinary catheter. Diagnoses included multiple sclerosis (MS), type 2 diabetes, and history of urinary tract infection (UTI). However, the MDS failed to identify R7 had a multi-drug resistant organism (MDRO). R7's care plan revised 8/9/24, identified R7 needed total assistance with toileting needs and catheter management. The care plan failed to identify R7's preferences for family involvement with her care nor to identify R7 had an MDRO. R7's Physical Therapy Skilled Nursing Facility Treatment Note dated 9/12/24, identified R7 had an open wound on her right ischial tuberosity and had an increased risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to follow provider's orders for intermittent catheterization for 1 of 1 resident (R99); and failed to ensure catheter care was provided in a manner to prevent potential urinary tract infection (UTI) for 1 of 3 residents (R7) reviewed for catheters. Findings include: R99's admission Minimum Data Set (MDS) dated [DATE], identified R99 had moderate cognition. R99 required intermittent catheterization and did not participate in a bladder program. Diagnoses included neurogenic bladder, Alzheimer's disease and dementia. R99's interagency transfer orders signed 10/24/24, identified orders for staff to perform scheduled straight catheterizations 4 times a day; If staff were consistently draining >500 mL per catheterization, then add a scheduled catheterization. R99's Bowel and Bladder Comprehensive assessment dated [DATE] identified R99 required intermittent catheterization every shift and as needed, requires extensive assist from staff with transfers on/off the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to thoroughly investigate an injury of unknown origin for 1 of 3 residents (R1) reviewed who sustained significant unexplained bruising. Findings include: R1's admission Record identified diagnosis that included Alzheimer's disease, dementia and age related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments on both sides. The MDS indicated R1 required substantial/maximal assistance from staff for toileting and transfers and did not ambulate. R1's care plan dated 1/19/24, identified vulnerabilities related to functional limitations and Alzheimers disease. R1's facility Progress Note (PN) dated 6/20/24, indicated writer was summoned to R1's room by nursing assistant (NA) at 6:50 p.m. who stated R1 had bruising to her left side. Writer…

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 assessment to determine potential causal factors of extensive bruising for 1 of 3 residents (R1) reviewed for non-pressure related skin concerns. In additional the facility failed to implement interventions to prevent further injury. Findings include: R1's admission Record identified diagnosis that included Alzheimer's disease, dementia and age related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments on both sides. The MDS indicated R1 required substantial/maximal assistance from staff for toileting and transfers and did not ambulate. R1's care plan dated 1/19/24, identified impaired cognitive functioning related to dementia and a potential for alteration in skin integrity and directed staff to observe skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an injury of unknown origin within 24 hours of it being identified to the State Agency (SA) for 1 of 3 residents (R1) reviewed for potential abuse. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had a severe cognitive impairment and a diagnosis of Alzheimer's disease. R1 was dependent on staff for all care areas. R1 exhibited physical and verbal behaviors towards others. R1's WSLC Skin Incident Report dated 11/29/30, identified staff reported bruising to R1's hand/arm/finger. It was reported R1 was combative during cares the evening prior. A bruise to the left wrist measured 8 centimeters (cm) by 26 cm. The top of hand bruise measured 4 cm x 3.4 cm. The right index finger bruise measures 6.2 cm from knuckle. Interventions included a physician order was obtained to get an x-ray, nurse assessment, and taping of the finger if R1 allowed. R1's Skin/Wound note dated 11/29/23 at 10:46 a.m., identified R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to thoroughly investigate an injury of unknown source to ensure resident safety and appropriate interventions were implemented for 1 of 3 residents (R1) reviewed for potential abuse. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had a severe cognitive impairment and a diagnosis of Alzheimer's disease. R1 was dependent on staff for all care areas. R1 exhibited physical and verbal behaviors towards others. R1's WSLC Skin Incident Report dated 11/29/30, identified staff reported bruising to R1's hand/arm/finger. It was reported R1 was combative during cares the evening prior. A bruise to the left wrist measured 8 centimeters (cm) x 26 cm. The top of hand bruise measured 4 cm x 3.4 cm. The right index finger bruise measures 6.2 cm from knuckle. Interventions included a physician order was obtained to get an x-ray, nurse assessment, and taping of the finger if R1 allowed. R1's Skin/Wound note dated 11/29/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to assess for dementia related behaviors and implement individualized resident centered interventions to managed the dementia symptoms for for 2 of 3 residents (R3, R1) reviewed for potential abuse. Findings include: R3 R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and a diagnosis of dementia. R3 exhibited physical and verbal behaviors toward others. R3's cognitive Loss/Dementia CAA dated 9/22/23, identified R3 demonstrated behavioral symptoms during the review period, including physical and verbal. R3 had a diagnosis of dementia which was the primary contributing factor to her cognitive function decline and behavioral symptoms. R3 also had a diagnosis of major depressive disorder that may contribute to her symptoms. R3 had a WanderGuard in place to reduce risk for elopement. Staff would continue with current interventions related to cognitive impairment and proceed to care plan. R3's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R7, R25, R34, R39, R43) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was [AGE] years old and had diagnoses of Parkinson's disease and breast cancer. R7's immunization record dated 11/29/23, identified R7 received the pneumococcal polysaccharide vaccine (PPSV23) on 6/17/15, and received the pneumococcal conjugated vaccine (PCV-13) on 5/22/17. R7's medical record did not include evidence R7 or R7's representative received education regarding pneumococcal vaccine booster and there was no indication R7 was offered the pneumococcal vaccine per CDC guidance. R25's significant change MDS dated [DATE], identified R25 was [AGE]…

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 did not self-administer medications as assessed for 1 of 1 residents (R39) observed to self administer medication after staff set up. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had moderate cognitive impairment and diagnoses included dementia, high blood pressure, and renal insufficiency. R39's Initial Evaluation of Ability of Resident to Self-Administer Drugs dated 2/27/23, identified R39 was not cognitively or physically able to self-administer medications. On 11/29/23 at 7:50 a.m., licensed practical nurse (LPN)-A dispensed the following medications into a medication cup: acetaminophen ES 500 milligrams (mg) 2 tabs (pain reliever), Calcitriol 0.25 micrograms (mcg) (a medication that treats low calcium levels caused by kidney disease), calcium 600 mg with Vitamin D3 10 mcg (a supplement that prevents low levels of calcium and vitamin D, Chlorthalidone 50 mg (a water pill),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to assess, monitor and implement mental health interventions for 1 of 1 resident (R28) who had identified behavior needs. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had moderate cognitive impairment and diagnoses that included dementia and malnutrition. R28 exhibited no depression or behavioral symptoms during the lookback period. R28's care plan revised 10/20/23, failed to identify R28's interventions for any behaviors. R28's psychosocial note dated 11/10/23, identified family member (FM)-A was updated on the subarachnoid hemorrhage in R28's parietal lobe. Discussed behavioral concerns and patterns R28 displayed when FM-A left the facility. FM-A explained R28 and FM-A got into an argument earlier in the week, FM-A told R28 she wouldn't be in to visit for awhile and R28 knew she was dog sitting this weekend. FM-A expected R28 would do something to create a fall as per FM-A, this was something R28 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to assess for and failed to ensure 1 of 2 residents (R4) was free from the use of physical restraints when placed in recliner chairs that prevented rising independently. Findings include: R4's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she required substantial assistance from staff for transfers and toileting. R4's care plan dated 6/29/23, identified a self care deficit and a risk for falls related to cognitive impairment and balance problems. The care plan directed staff to ensure call light in reach, anticipate needs, and use of alarms. R4's facility Progress Note dated 10/23/23, indicated R4's alarm sounded and she was found on her hands and knees on the floor at the foot of the recliner which was still reclined. R4 was unable to verbalize what she was trying to do. During observation on 11/22/23, at 9:46 a.m. R4 was seated in a power recliner chair in a common area of the unit. NA-C stated R4 used 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.